Nokea
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.
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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.
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).
What are the acronyms used to indicate the quadrants of the abdomen?
- A. RLQ
- B. LMQ
- C. LUQ
- D. RMQ
- E. RUQ
- F. LLQ
Correct Answer: A,C,E,F
Rationale: The abdomen is divided into four quadrants: RLQ (right lower quadrant), LUQ (left upper quadrant), RUQ (right upper quadrant), and LLQ (left lower quadrant).
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.
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.