Nokea
Which of the two heart sounds is the loudest?
- A. S1
- B. S2
- C. S3
- D. S4
Correct Answer: A
Rationale: S1 is typically louder than S2 because it involves the closure of the mitral and tricuspid valves, which produce a stronger sound.
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You have assessed the patient's pupils by shining a light into both pupils as you learned to assess both pupil reflexes and accommodation response. What acronym would you document that would indicate that all findings were within normal parameters?
- A. PERRLA
- B. PEARL
- C. PERRL
- D. PARLA
Correct Answer: A
Rationale: PERRLA stands for Pupils Equal, Round, Reactive to Light, and Accommodation, indicating normal pupil findings.
Another nurse working on your floor reports that one of the patients has an apical pulse of 87 bpm and a pulse deficit of 9. You know that means the patient's radial pulse was
- A. 96 bpm
- B. 87 bpm with 9 skips
- C. 78 bpm
- D. 9 bpm
Correct Answer: C
Rationale: Pulse deficit is the difference between apical and radial pulse rates; 87 bpm (apical) - 9 = 78 bpm (radial).
During assessment of your patient, you notice that the patient has numbness of the left side of her face. You would use the medical term to document this finding.
- A. Paresthesia
- B. Hypoesthesia
- C. Anesthesia
- D. Dysesthesia
Correct Answer: B
Rationale: Hypoesthesia is the medical term for reduced sensation or numbness in a specific area, such as the face.
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.
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.