RN preparing to examine client with stage 3 lymphedema affecting the right leg. What does the nurse expect to find?

Nonpitting edema that feels hard and lumpy

A pregnant female in her third trimester is in clinic for “leg pain and swelling” How should RN assess for DVT?

Assess for increased pain with dorsiflexion of foot

Exam of older pt presenting with “cough & weight gain” reveals bilateral edema in legs. What should RN do next?

Observe neck veins for distention

While assessing a 3 month old infant RN offers finger to baby’s palm and baby tightly grasps it. How RN report findings

This response is expected at this age

RN examining 3 month old because he “isn’t gaining weight”, to screen for cardiac dysfunction what question is important

Does he seem to get short of breath or sweat while feeding?

Which collection of sign/symptoms is most consistent with acute coronary syndrome?

Heavy aching chest pain with dizziness and pallor

During an assessment of a health pt where would RN expect to palpate the point of maximal impulse?

5th ICS at or medial to midclavicular line

The RN is educating post menopausal women on ways to prevent osteoporosis. Which is best way to prevent bone loss?

Preforming physical activity such as fast walking

When auscultating over a patients femoral arteries the RN notices the presence of a bruit on the left side Which is true

Occurs with turbulent blood flow indicating partial occlusion

RN testing function of CN III. Which best describes the response the nurse should expect if this nerve is intact?

Both eyes move vertically with extra ocular movements

While performing a head to toe assessment on a bedridden pt with diabetes, RN unable to palpate pedal pulses. Next step?

Use a Doppler to check blood flow

While assessing a 7mo infant nurse clasps hands and notices abduction and flexion of arms & legs & bring legs to body…

This reflex should have disappeared by 4 months of age

RN hears loud rumbling murmur right after S2 at apical site. Palpable thrill present. How would RN document?

Grade 4/6 diastolic mitral murmur

During assessment pt reports being treated for osteoarthritis What finding alerts RN to presence of Bouchard’s nodes?

Proximal interphalangeal joint nodules

RN assessing pt with “left shoulder pain” to assess for rotator cuff injury what should RN do?

Assess the patients ability to abduct the arms

When RN is auscultating the carotid artery for bruits which of these statements reflects the correct technique?

Lightly apply bell over carotid artery pt to deep breath exhale & hold it

RN preparing to preform modified Allen test on hospitalized pt. A nursing student asks why test is necessary. RN says?

used to evaluate adequacy of collateral circulation to cannulate radial art

The RN is preforming a CN exam on on a pt who had a stroke 2 days prior. How should the nurse assess CN X?

Assess the clients ability to swallow

RN is assessing the jugular veins, which technique is correct?

A penlight should be used to highlight distention or pulsation

RN performing complete exam in older pt. Which of the following is a normal age associated change

Stiffening of arterial walls resulting in a wider pulse pressure

Pt recover from MI & complains of “sharp chest pain” on exam RN hears high pitch scratchy sound during S1 & S2 at apex..

Inflammation of pericardial membrane

During cardiac auscultation of healthy adult RN hears intermittent extra early diastolic sound at 2nd L ICS. Next step?

Watch the patients respirations while listening for effect on the sound

During check up exam of 86 year old pt the RN assess a slower gait, slower pupillary response and 1+ DTR. How RN note?

Normal changes attributed to aging

A pt with peripheral arterial disease and associated paresthesia is most likely to report what during health history?

“I often have pins and needles feeling in my foot”

The RN preparing to assess posterior tibialis artery. Where is correct location for palpation?

In the groove behind the medial malleolus

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Exam 4

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1
RN preparing to examine client with stage 3 lymphedema affecting the right leg. What does the nurse expect to find?
Nonpitting edema that feels hard and lumpy
Redness and swelling of the calf
Pallor of right leg with absent pulses
Severe edema that leaves an indentation when palpated
2
A nurse is assessing a pt admitted for severe hyperthyroidism. When assessing pt pulses, what should nurse expect?
Nonpalpable
Bounding (3+)
Weak, thready (1+)
Normal (2+)
3
Which sign or symptom is most consistent with left sided heart failure?
Dependent edema
Cough
JVD
Weight gain
4
When the RN is testing the biceps reflex what is the expected response?
Flexion of the fingers
Flexion of the arm
Supination of the hand
Extension of the forearm
5
RN testing DTR on adult for annual physical. What response does RN expect to find when testing Achilles reflex?
Flexion of the knee
Extension of the lower leg
Dorsiflexion of foot
Plantar flexion
6
The RN places a key in the hand of a pt and he identifies it as a marble. What term would RN use to describe finding?
Failed monofilament test
Extinction
Abnormal point location
Astereognosis
7
RN preforming exam on pt who says “always dropping things & tripping” RAM are slow and frequently misses. RN suspects?
Lesions on cranial nerve XI
Cognitive dysfunction
Vestibular disease
Dysfunction of cerebellum
8
The nurse is gathering a health history nurse. Which of following is a risk factor for peripheral vascular disease?
Consumption of 1 alcoholic drink per day
High levels of HDL cholesterol
Age > 70
Occupation requires a lot of walking
9
A pregnant female in her third trimester is in clinic for “leg pain and swelling” How should RN assess for DVT?
Assess for elevation pallor bilaterally
Observe for atrophy of lower leg muscles
Assess for increased pain with dorsiflexion of foot
Check ankle brachial index (ABI) on affected leg
10
During systole which valves are heard closing?
Aortic valves
SL valves
AV valves
Pulmonic valves
11
The left ventricle normally pumps blood directly to the
Aorta
Pulmonary artery
Vena cava
Left atrium
12
Pt presents to clinic with a “swollen knee”. What test should RN use to check for large amounts of fluid around patella?
McMurray test
Ballottement
Lasegue test
Tinsel sign
13
RN examine pt w/ “leg weakness” Guillian Barre is suspected What might RN find when testing reflexes in lower extremitie
Hyperreflexia
Positive babinski
Hyporeflexia
Normal reflexes
14
During exam of pt with “back pain’ after car accident RN notices lateral lifting & forward flexion of spine. RN suspect?
Herniated nucleus pulposus
Pelvic fracture
Effusion of knee
Scoliosis
15
Exam of older pt presenting with “cough & weight gain” reveals bilateral edema in legs. What should RN do next?
Suspect coronary artery disease as cause for these symptoms
Assume chronic venous insufficiency and notify the provider
Observe neck veins for distention
Obtain ankle brachial index (ABI) bilaterally
16
The RN is assessing for PAD and calculates an ankle brachial index of 0.8. The nurse knows
She should assess the pulse deficit next
This is indicative of venous insufficiency
This is indicative of PAD
Anything below 0.9 is not indicative of PAD or venous insufficiency
17
Which of the following is not a component of the GCS?
Motor response
Reflex response
Eye opening
Verbal response
18
Where would the nurse expect to hear the loudest sound from S2?
Base
Apex
19
While assessing a 3 month old infant RN offers finger to baby’s palm and baby tightly grasps it. How RN report findings
This response is expected at this age
This is consistent with frontal lobe damage
This reflex should have disappeared after birth
Persistence of Moro reflex can indicate neurological damage
20
RN examining 3 month old because he “isn’t gaining weight”, to screen for cardiac dysfunction what question is important
What formula are you using this time around ?
How many poopy diapers is he having per day?
Does he seem to get short of breath or sweat while feeding?
Does he pee more at night than during the day?
21
A healthy 75 year old male asks RN why he is getting shorter as he ages. How should RN respond?
As you loose weight you appear shorter
Long bones in the arms and legs shorten with age
The spinal a column shortens
Lordosis can cause you to appear shorter than you are
22
RN examining pt w/ diastolic dysfxn Auscultation w/ bell RN hears late diastolic sound at 5th ICS L midclavicular line
Atrial gallop
Split S2
Split S1
Midsystolic click
23
Which collection of sign/symptoms is most consistent with acute coronary syndrome?
Radiating chest discomfort that fully subsides with rest
Heavy aching chest pain with dizziness and pallor
Epigastric pain exacerbated by food
Pulsations and “stabbing” chest pain with deep breaths
24
During an assessment of a health pt where would RN expect to palpate the point of maximal impulse?
3rd L intercostal space at midclavicular line
4th L ICS at anterior axillary line
5th ICS at or medial to midclavicular line
4th ICS at sternal border
25
The RN is educating post menopausal women on ways to prevent osteoporosis. Which is best way to prevent bone loss?
Assessing bone density annually after age 30
Avoiding hormone replacement therapy
Preforming physical activity such as fast walking
Eating plenty of Vitamin C rich foods
26
When auscultating over a patients femoral arteries the RN notices the presence of a bruit on the left side Which is true
Femoral artery bruits are caused by hyper metabolic states
Often associated with venous disease
Occur in presence of lymphadenopathy
Occurs with turbulent blood flow indicating partial occlusion
27
The RN is examining a 1 hour old baby. Which finding is most concerning?
Apical impulse is palpated at the 4th ICS left MCL
Resting heart rate is 88 bpm
Blue tint to the hands and feet
Soft systolic murmur
28
RN testing function of CN III. Which best describes the response the nurse should expect if this nerve is intact?
Both eyes move vertically with extra ocular movements
Pt moves head and shoulders against resistance with equal strength
Pt demonstrates ability to hear normal conversation
When pt sticks out tongue it is midline and without tremors or deviation
29
While performing a head to toe assessment on a bedridden pt with diabetes, RN unable to palpate pedal pulses. Next step?
Notify healthcare provider
Use a Doppler to check blood flow
Palpate pulse points with legs dependent
Apply a heating pad to both feet to stimulate blood flow
30
While assessing a 7mo infant nurse clasps hands and notices abduction and flexion of arms & legs & bring legs to body…
This tonic neck reflex should have disappeared at 6 months
This reaction is an expected startle response at this age
This response is normal as long as the movements are bilaterally symmetric
This reflex should have disappeared by 4 months of age
31
RN hears loud rumbling murmur right after S2 at apical site. Palpable thrill present. How would RN document?
Grade 3/6 diastolic pulmonic murmur
Grade 5/6 late systolic tricuspid murmur
Grade 6/6 early systolic apical murmur
Grade 4/6 diastolic mitral murmur
32
A pt has been diagnosed with tricuspid stenosis. What s/s would the nurse expect?
Narrow pulse pressure
Dependent edema
Orthopnea
Chest pain
33
During assessment pt reports being treated for osteoarthritis What finding alerts RN to presence of Bouchard’s nodes?
Non tender enlargement of distal interphalangeal joints
Proximal interphalangeal joint nodules
Frozen non movable phalangeal joints
Proximal intertarsal joint swelling of big toe
34
RN assessing pt with “left shoulder pain” to assess for rotator cuff injury what should RN do?
Evaluate muscle tone bilaterally
Assess the patients ability to abduct the arms
Check for a positive bulge sign
Assess arm span with a tape measure
35
When RN is auscultating the carotid artery for bruits which of these statements reflects the correct technique?
Listen with the bell of stethoscope, pt asked to take a deep breath & hold
Lightly apply bell over carotid artery pt to deep breath exhale & hold it
Place diaphragm firmly over carotid artery & pt tk deep breath, exhale hold
Auscultate one side with bell & palpate carotid artery on other side
36
Which deformity is not typically associated with Rheumatoid arthritis?
Ulnar deviation
Swan neck deformities
Herberdens nodes
Boutonnière deformities
37
RN preparing to preform modified Allen test on hospitalized pt. A nursing student asks why test is necessary. RN says?
Used to evaluate adequacy of cap patency before venous blood draws
used to evaluate adequacy of collateral circulation to cannulate radial art
evaluate venous refill w/ occurs after ulnar & radial arteries temp occlude
It is used to measure rate of lymphatic drainage
38
A pt tells RN that her fingers often “go numb & then burn” when she is very stressed or goes out in colder weather. ????
Chronic arterial insufficiency
Lymphedema
Deep vein thrombosis
Raynaud phenomenon
39
The RN is preforming a CN exam on on a pt who had a stroke 2 days prior. How should the nurse assess CN X?
Test muscle strength in the neck
Assess the clients ability to swallow
Preform the whisper test
Observe for a midline protrusion of the tongue
40
RN is assessing the jugular veins, which technique is correct?
Unilateral JVD consistent with right sided heart failure
A penlight should be used to highlight distention or pulsation
The jugular veins should be auscultated for bruits
The RN should keep the head of bed flat when assessing for JVD
41
What should RN incorporate when assessing motor coordination of a 10 month old infant?
Ensuring startle, rooting and tonic neck reflexes are still intact
Rapid alternating movements (RAM)
Denver II screening tool
Deep tendon reflexes (DTR’s)
42
If an S2 split is physiologic the sound should appear only with:
Expiration
Rest
Inspiration
Exercise
43
RN performing complete exam in older pt. Which of the following is a normal age associated change
Resting heart rate decreases over time
Stiffening of arterial walls resulting in a wider pulse pressure
Decline in blood pressure due to decreased cardiac output
Pain with hip adduction and abduction
44
Pt recover from MI & complains of “sharp chest pain” on exam RN hears high pitch scratchy sound during S1 & S2 at apex..
Ventricular atrophy resulting from muscle damage
Increased cardiac output
Inflammation of pericardial membrane
Systolic and diastolic regurgitation
45
During cardiac auscultation of healthy adult RN hears intermittent extra early diastolic sound at 2nd L ICS. Next step?
Watch the patients respirations while listening for effect on the sound
No further assessment is needed because RN knows this sound is an S3
Utilize a Doppler area over the device
Document diastolic murmur
46
During check up exam of 86 year old pt the RN assess a slower gait, slower pupillary response and 1+ DTR. How RN note?
Increased intracranial pressure
Consistent with Parkinson’s disease
Normal changes attributed to aging
Peripheral nervous system dysfunction
47
Using the diaphragm the RN hears intermittent extra early diastolic sound at base of the heart. This is most likely
Split S1
Atrial gallop
Split S2
Ventricular gallop
48
A pt with peripheral arterial disease and associated paresthesia is most likely to report what during health history?
“It feels much better when I walk or elevate my legs”
“I often have pins and needles feeling in my foot”
“Wearing my compression socks at work helps a lot”
“My legs are so swollen and heavy at the end of the day”
49
The RN preparing to assess posterior tibialis artery. Where is correct location for palpation?
In the groove behind the medial malleolus
Behind the knee
Over lateral malleolus
Lateral to extensor tendon of great toe
50
When listening to heart sounds which valve closures are heard best at apex of the heart?
Mitral and tricuspid
Mitral and pulmonic
Tricuspid and aortic
Aortic and pulmonic
51
During health history interview pt with hyperlipidemia feels pressure in chest during activity and stops after rest
Transient ischemic attack
Peripheral arterial disease
Coronary artery disease
Normal age related chest pain
52
RN preparing to auscultate for heart sounds in an elderly client presenting with cough & fatigue Which technique is best
Listening to sounds only at aortic, tricuspid, pulmonic and mitral areas
Listen to each valve site for a full minute
Auscultate all heart sounds with client in right side lying position
Listen by inching stethoscope in Z pattern from base of heart to apex
53
The RN is preparing to preform a cardiovascular exam on elderly pt. What age associated change does RN expect to find?
Decreased resting heart rate
Carotid bruit
Wider pulse pressure
Third heart sounds
54
RN is reviewing risk factors for venous disease. Which of these situations best describes a person at risk for venous dz
Pt with hypertension and hyperlipidemia
Person with 5 year, 1 pack per day smoking habit
Client with BMI of 38 and a sedentary job
Older adult taking anticoagulant medication
55
During assessment of pt at annual exam RN unable to palpate ulnar pulses. Cap refill is 1 sec. What should RN do next?
Preform a modified Allen test to check patency
Consider this finding normal and proceed with peripheral vascular eval
Refer individual for further evaluation
Check for presence of claudication
56
RN examining pt admitted for pancreatitis. Vital signs are 98.6 F pulse 98 respirations 18 & cap refill 4 sec bilateral
Consider delayed cap refill time and investigate further
Suspect that pt has venous insufficiency
Consider this a normal cap refill time that requires no further assessment
Ask pt about history of frostbite
57
RN testing reflexes on adult pt when stroking up lateral side of sole and ball of foot RN sees plantar flexion of toes..
Normal 2+ reflex
Palmar grasp intact
Plantar reflex present
Positive babinski sign
58
RN completing neuro assessment of 68 yo pt with “difficulty walking” How should RN assess muscle tone in this pt?
RN asks to relax his muscles completely and then moves each joint full ROM
Ask pt to resist your attempts to move his extremities
Observe overall muscle bulk of client when standing
Utilize percussion hammer to assess reflex responses
59
RN using Phalen test in exam of pt with “hand pain”. What instruction should RN give pt to preform test?
Stand here while I tap on your wrist area
Hyperextend wrists w/ palmar surfaces of both hands touching & wait 60 sec
Type on this keyboard and let me know if you feel pain
Hold both hands back to back for 60 seconds
60
During neuro assessment of pt with a stroke RN places two pins on client skin pt feel 16 mm one point on R index finger
An abnormal response as a result of a sensory cortex lesion
Suspicious of a cerebellum lesion, RN should assess their gait
Consistent with occipital lobe damage
A normal response in the middle aged adult
61
RN preforming assessment on elderly pt with limited ROM in knee. Which assessment finding is consistent with this data?
Absence of bulge sign
The patient has a deliberate gait with a wider stance
Quadriceps strength is 4/5 bilaterally
Client displays a limping gait
62
When assessing 68 year old pt presenting with L leg pain RN notes L femoral pulse is very weak. What should Rn do next?
Palpate for enlarged lymph nodes in the area
Auscultate the site to identify partial occlusion
Document finding as normal in older adult
Ask pt to stand and palpate again
63
Pt presents to clinic with swelling in legs Exam reveals distended neck veins and pansystolic murmur at 4th ICS????
Aortic insufficiency
Mitral stenosis
Pulmonic stenosis
Tricuspid regurgitation
64
A pt complains of leg pain waking at night but pain disappears when dangles them over the bed & sore on great toe. ?????
Problems related to arterial insufficiency
Pain related to musculoskeletal abnormalities
Problems related to venous insufficiency
Pain related to lymphatic abnormalities
65
A nurse is caring for a stable pt with significant swelling from a musculoskeletal injury. The nurse would be prudent to
Check a respiratory rate
Check for poikilothermia
Check for varicose veins
Have the pt elevate the limb to reduce swelling
66
RN examining pt with severe HTN and coronary artery disease. How should RN auscultate for S4 gallop?
Using diaphragm of stethoscope in aortic area with patient sitting
Use bell of stethoscope at apex with pt in left lateral position
Using bell of stethoscope at base with patient leaning forward
Use diaphragm of stethoscope in pulmonic area with pt supine
67
A 65 year old pt experiencing pain in left calf when he exercises which disappears after resting for a few minutes….
Ischemia caused by the complete blockage of an artery
Claudication due to venous abnormalities
Partial blockage of an artery
Venous obstruction
68
RN examining elderly pt with HTN. During cardiac auscultation using bell RN hears extra late diastolic sound at apex
Atrial gallop
Split S2
Ventricular gallop
Split S1
69
During assessment with Glasgow coma scale nurse depresses clients sternum and notices flexion and upper extremities
Withdrawals from painful stimulus
Decorticate posturing
Motor response 2/5
Decerebrate posturing
70
RN examining pt with systolic dysfunction. Using bell nurse hears extra early diastolic sound at apex of heart. Sound?
Split S1
Split S2
S3 gallop
S4 gallop
71
An RN is auscultating apical and palpate radial pulse simultaneously and note apical pulse is faster what does this mean
This is a normal finding
THis is not possible the RN should remeasure
This is an abnormal finding and indicates weak ventricular contraction
72
RN examining a newborn who was born with assistance of forceps. Which finding alerts RN to possible fractured clavicle?
Limited movement on one side during Moro reflex
Positive Ortilani sign
Absence of a rooting reflex
Heart rate 136
73
RN assessing carotid arteries on a pt. The RN should do all of the following except?
Assess the pulse for a 0-3+ scale
Auscultate in three areas bilaterally
Listen for bruits using the bell
Simultaneously palpate the arteries for a thrill
74
True or false the PMI should be palpable at 5-6th ICS at anterior axillary line
False
True
75
During an exam the RN notices severe nystagmus in both eyes of pt. What conclusion by the nurse is correct?
A normal occurrence
A sign the patient is nervous about the exam
Indicates visual problem and a referral to an ophthalmologist is indicated
Indicated disease of cerebellum of brain stem
76
Adult pt with flank pain and blood in urine. During exam RN notices hard painless nodules on great toe, one burst…
Rheumatic fever
Osteoarthritis
Gout
Bunions
77
The RN is preforming a complete neuro exam on an adult. How should RN assess cognitive function?
“Tell me where you are right now”
“Walk heel to toe across the room”
“Tell me when you feel the cotton wisp touch your skin”
“Close your mouth and don’t let me open it”
78
RN is auscultating a pt with the bell of stethoscope and hears early diastolic sounds which is S3 what does this mean?
Right sided heart failure
Systolic heart failure
Diastolic dysfunction
Transient ischemic attack
79
A pt is reporting pain in most of his joints worse in the morning but gets better after moves around. RN assess for what
Gout
Osteoarthritis
Intermittent claudication
Rheumatoid arthritis
80
Which is not a symptom of L sides heart failure?
Tachycardia
Cough
Orthopnea
Dependent edema
81
The RN is preforming a neuro assessment on a 7 year old. What would the RN include in the cranial nerve portion of exam?
Hop up and down on one foot
Walk across the room like you’re walking on a tight rope
I’m going to make some silly faces and I want you to copy me
I’m going to use my finger to tap on your arm
82
Which sign or symptom is most consistent with severe mitral valve stenosis?
Weight gain
Jugular vein distention
Bounding peripheral pulses
Pulmonary edema
83
When assessing cerebellum function on adult pt RN should ask pt to…
Resist my attempt to move your left arm
Alternate touching your nose and my finger
Stare straight ahead while I shine this penlight in your eye
Close your eyes and tell me what number I draw on your hand
84
When assessing muscle strength RN observes pt maintain bicep flexion against resistance. How should RN document strength
5/5
2+
Full tone
Bounding
85
An RN is auscultating with diaphragm and hears an S1 split. Where in cardiac cycle would this be found?
Early systolic
Late diastolic
Early diastole
Late systole
86
Which statement best describes the S1 heart sound?
Louder than S2 at the base of the heart
It is caused by closure of semilunar valves
Indicates beginning of diastole
Coincides with carotid artery pulse
87
RN completing neuron exam on elderly pt. Which finding is expected?
Slower more deliberate gait with a wider stance
Hyperactive deep tendon reflex
Smaller pupils with absent light reflex
Asymmetric tracking of the eyes
88
Which of the following is not a type of murmur?
Pathological
Functional
Paradoxical
Innocent
89
RN auscultate loud murmur after S2 over pulmonic valve area. Slight thrill palpated over area. Nurse documents
Grade 5/6 systolic murmur present at L upper sternal border
Grade 6/6 systolic murmur present at L midclavicular line
Grade 4/6 diastolic murmur present at 2nd L intercostal space
Grade 5/6 diastolic murmur is present at 4th L intercostal space
90
RN preparing to examine pt with severe HTN and coronary artery disease. How should nurse auscultate for S4 gallop?
Use diaphragm of stethoscope in pulmonic area with pt supine
Use diaphragm of stethoscope in aortic area with patient sitting
Use bell of stethoscope at base with patient leaning forward
Use bell of stethoscope at apex with patient in left lateral position
91
A positive Homan’s sign might indicate what?
PVD
DVT
Myocardial infarction
Heart failure
92
RN examining school aged child Using bell, RN hears midsystolic soft blowing whooshing at L middle sternal border……
Systolic murmur
S3 gallop
Diastolic murmur
S4 gallop
93
Adult pt seen for severe infection in left foot Which of these findings should the nurse expect to see during assessment
Hard and fixed popliteal nodes
Enlarged and tender inguinal lymph nodes
Pellet like nodes in axillary region
Tender and movable cervical nodes
94
During a cardiac assessment on pt with “chest pain” nurse finds bilateral JVD, dependent edema, and distended abdomen
Right sided heart failure
Peripheral vascular disease
Left sided heart failure
Severe dehydration
95
RN is assessing 36 wk pregnant pt & hears extra early diastolic sound at apex of heart. This sound is most likely?
A pulmonic valve dysfunction
A normal finding
An early sign of heart failure
A split S1
96
The RN wants to examine a pt’s apical impulse, where should this be found?
5th ICS L MCL
6th ICS
5th ICS L midaxillary line
2nd ICS R sternal border
97
Which pt should you preform a complete musculoskeletal exam on?
A pt who is having trouble standing in the shower
A pt with severe stomach pain
A diabetic pt with a new injury on his right toe
A patient with a head injury and one sided weakness
98
During an assessment of a 67 year old man RN notices pt has stooped posture, shuffling gait and resting hand tremor…
Multiple sclerosis
Delirium
Hemiparesis
Parkinsonism
99
Assessment of pt with “fatigue” RN notes apical impulse easily palpable over 5th and 6th ICS anterior axillary line…??
Dehydration
Ventricular dilation
Cardiac atrophy
A normal functioning heart
100
The RN notes a 10 degree lateral rotation to the spine. The RN knows
Assess flexion of the spine
This is normal
Okay as long as it doesn’t affect ADL’s
This is an abnormal finding

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