Nokea
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.
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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.
The cone portion of each lung extends approximately 1 inch above the medial aspect of the clavicle and is called what?
- A. Lower lobe
- B. PMI
- C. Bronchus
- D. Apex
- E. Base
Correct Answer: D
Rationale: The apex is the top portion of the lung extending above the clavicle.
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 examination of the eyes, you check something known as consensual reflex. How is this done?
- A. Shine a light into one eye and observe pupil constriction in both eyes
- B. Shine a light into one eye and observe pupil dilation in the other eye
- C. Ask the patient to follow a moving object with both eyes
- D. Check pupil size in a darkened room
Correct Answer: A
Rationale: Consensual reflex is tested by shining a light into one eye, causing constriction in both the illuminated and opposite pupil.
Explain the importance of performing an initial shift assessment within the first hour of your shift.
- A. Ensures early detection of changes in patient condition
- B. Establishes a baseline for comparison
- C. Guides care planning and interventions
- D. All of the above
Correct Answer: D
Rationale: An initial shift assessment within the first hour establishes a baseline, detects changes, and guides care planning.