Nokea
You know that when assessing the pulse there is more than one characteristic you should assess. Which of the following best identifies the characteristics you must assess?
- A. Rate, rhythm, and strength
- B. Rate, volume, and strength
- C. Regularity and number of beats per minute
- D. Site of PMI, rate, and strength
Correct Answer: A
Rationale: Pulse assessment includes rate (beats per minute), Rhythm (regular or irregular), and strength (force of the pulse).
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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.
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.
Which of the following would be the most accurate description of dorsal flexion assessment?
- A. Ask the patient to press his or her toes toward the foot of the bed, applying pressure against the palms of your hands so you can assess the strength and equality of the flexion between the two sides
- B. Ask the patient to pull his or her toes toward the head, pulling against the palms of your hands so you can assess the strength and equality of the flexion between the two sides
- C. Ask the patient to gently point his or her toes toward the foot of the bed so you can assess agility and coordination of the lower extremities
- D. Ask the patient to gently point his or her toes toward the head so you can assess the neuromuscular activity of his lower extremities
Correct Answer: B
Rationale: Dorsal flexion involves pulling the toes toward the head, assessed for strength and equality against resistance.
A patient was admitted yesterday with pneumonia. When auscultating his breath sounds you detect rales in the right lower lobe. How quickly should you reassess this abnormal finding?
- A. Within 15 minutes
- B. Within 60 minutes
- C. In less than 2 hours
- D. In 4 hours or less
- E. When the patient complains of dyspnea
Correct Answer: C
Rationale: Rales (crackles) indicate fluid in the lungs, requiring reassessment within 2 hours to monitor for worsening pneumonia or respiratory distress.