Nokea
Which of the following assessment findings may provide you with neurological status data?
- A. Thick, dirty hair
- B. Lethargy
- C. Color of the lower extremities
- D. Edema of the left hand and arm
- E. Pulse rate of 44 bpm
Correct Answer: B
Rationale: Lethargy is a neurological finding indicating altered mental status, while other options relate to physical appearance or circulatory issues.
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The acronym PMI stands for what? Which means what?
- A. Point of maximum impulse, strongest heart beat
- B. Pulse measurement index, pulse strength
- C. Primary medical inspection, initial assessment
- D. Point of mitral intensity, mitral valve sound
Correct Answer: A
Rationale: PMI stands for 'point of maximum impulse,' the location where the heart's apex beat is strongest, typically at the 5th intercostal space.
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.
You are preparing to perform an initial shift assessment. You know that the correct order in which you should perform the five techniques for objective assessment (except for 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: The correct order for assessment (except abdomen) is observation, auscultation, palpation, percussion, and olfaction to avoid altering findings.
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).
Abnormal sounds that can be auscultated over the lung fields are called
- A. Crackles
- B. Wheezes
- C. Rhonchi
- D. Stridor
- E. Pleural friction rub
Correct Answer: A,B,C,D,E
Rationale: Abnormal lung sounds include crackles (rattling sounds), wheezes (high-pitched whistling), rhonchi (low-pitched rattling), stridor (high-pitched sound during breathing), and pleural friction rub (grating sound due to pleural inflammation).