Nokea
Which lobe(s) of the lungs is(are) accessible for auscultation only posteriorly and laterally?
- A. The left upper lobe
- B. The left lower lobe
- C. The right upper lobe
- D. The right middle lobe
- E. The right lower lobe
Correct Answer: B,E
Rationale: The left and right lower lobes are accessible posteriorly and laterally due to their anatomical position.
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What type of assessment is performed on admission?
- A. A focused assessment
- B. An initial head-to-toe shift assessment
- C. A comprehensive health assessment
- D. A brief admission systems assessment
- E. Disease and injury assessment
Correct Answer: B,C
Rationale: A comprehensive health assessment (C) is typically performed on admission to gather baseline data, often including an initial head-to-toe shift assessment (B) to evaluate all body systems.
While assessing the patient's oral mucosa, you detect severely unpleasant sour breath. What is the correct medical terminology for this finding?
- A. Halitosis
- B. Fetor oris
- C. Malodor
- D. Xerostomia
Correct Answer: A
Rationale: Halitosis is the medical term for bad breath, including sour or unpleasant odors from the mouth.
Which lobe(s) of the lungs is(are) accessible for auscultation both anteriorly and posteriorly?
- A. The left upper lobe
- B. The left lower lobe
- C. The right upper lobe
- D. The right middle lobe
- E. The right lower lobe
Correct Answer: A,C
Rationale: The left and right upper lobes can be auscultated anteriorly and posteriorly due to their position in the chest.
You have just completed an initial shift assessment of your 72-year-old female patient who has congestive heart failure. Which of the following assessment findings causes you the most concern?
- A. Fine papular rash under both breasts
- B. Reports her last BM was 2 days ago
- C. AP 78 regular and distant
- D. Has not voided in 12 hours
- E. Complaints of fatigue
Correct Answer: D
Rationale: Not voiding in 12 hours is concerning in a patient with congestive heart failure, as it may indicate worsening renal perfusion or fluid retention.
Which of the following would be the most accurate description of dorsal flexion assessment?
- A. Ask the patient to press his or her toes toward the foot of the bed, applying pressure against the palms of your hands so you can assess the strength and equality of the flexion between the two sides
- B. Ask the patient to pull his or her toes toward the head, pulling against the palms of your hands so you can assess the strength and equality of the flexion between the two sides
- C. Ask the patient to gently point his or her toes toward the foot of the bed so you can assess agility and coordination of the lower extremities
- D. Ask the patient to gently point his or her toes toward the head so you can assess the neuromuscular activity of his lower extremities
Correct Answer: B
Rationale: Dorsal flexion involves pulling the toes toward the head, assessed for strength and equality against resistance.