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Which of the following assessment findings is not within the textbook normal range?
- A. 23 bowel sounds per minute in each quadrant
- B. Capillary refill of 5 seconds in a 41-year-old male patient
- C. Respiratory rate of 24 per minute
- D. Systolic pressure of 86 mm Hg
- E. Diastolic pressure of 62 mm Hg
Correct Answer: B,D
Rationale: Capillary refill of 5 seconds (normal is <2-3 seconds) and systolic pressure of 86 mm Hg (normal is 90-120 mm Hg) are outside normal ranges.
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If you hear a shrill, high-pitched, crowing sound coming from the room of a 3-year-old child who has croup, you recognize the ominous sign known as
- A. Crackles
- B. Rhonchi
- C. Wheezes
- D. Pleural friction rub
- E. Stridor
Correct Answer: E
Rationale: Stridor is a high-pitched, crowing sound associated with upper airway obstruction, common in croup.
Score the patient responses on the Glasgow Coma Scale. Calculate the patient's total score. Would you consider this patient as having a significant neurological impairment?
- A. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 2, Total: 8, Significant impairment
- B. Eye opening to pain: 2, Withdraws from pain: 5, Incomprehensible sounds: 2, Total: 9, Moderate impairment
- C. Eye opening to pain: 3, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 10, Moderate impairment
- D. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 9, Moderate impairment
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain (2), withdraws from pain (4), incomprehensible sounds (2), total = 8, indicating significant neurological impairment (score ?¤8 is severe).
The correct sequence to assess the abdomen is
- A. Auscultation, olfaction, observation, palpation, and percussion
- B. Observation, auscultation, palpation, percussion, and olfaction
- C. Observation, palpation, percussion, auscultation, and olfaction
- D. Olfaction, auscultation, observation, palpation, and percussion
- E. Olfaction, observation, auscultation, percussion, and palpation
Correct Answer: B
Rationale: Abdominal assessment starts with observation, then auscultation (before palpation/percussion to avoid altering bowel sounds), followed by palpation, percussion, and olfaction.
Describe the assessments that should be performed in relation to these limited data.
- A. Skin turgor, mucous membrane moisture, pressure ulcer risk
- B. Capillary refill, weight, urine output
- C. Edema, skin integrity, mobility
- D. All of the above
Correct Answer: D
Rationale: For a dehydrated, bedridden patient, assess skin turgor, mucous membranes, pressure ulcer risk, capillary refill, weight, urine output, edema, skin integrity, and mobility.
During palpation of the patient's abdomen, he flinches and tightens the abdominal muscles where you are palpating. This tightening of abdominal muscles is known as
- A. Guarding
- B. Rigidity
- C. Rebound tenderness
- D. Distension
Correct Answer: A
Rationale: Guarding refers to the involuntary tightening of abdominal muscles in response to pain or palpation, often indicating discomfort or pathology.