A lot of different stuff : T&P

Question 1

An abnormal sensation, typically tingling or pricking, caused chiefly by pressure on or damage to peripheral nerves ?

Accepted Answer

Paraesthesia

Question 2

While assessing a px&#x27;s neurologic sys., a nurse should ask them to close their eyes & identify which of the following ?

Accepted Answer

A familiar object the nurse places in the hand

Question 3

After a change of shift, you are assigned care for the following patients. Which patient should you assess first ?

Accepted Answer

50 y/o with asthma who complains of shortness of breath

Question 4

Which of the following is a first action during the physical assessment of a client ?

Accepted Answer

Inspect the client

Question 5

Peripheral temperature may be different in reference to the skin, what body parts would that include ?

Accepted Answer

Hands & Feet

Question 6

When performing an assessment on a group of clients, which of the following lesions should be identified as vesicles ?

Accepted Answer

Herpes Simplex, Varicella

Question 7

The BP of a px with a fractured femur is 140/94, and they deny any hx of hypertension. What action should be taken 1st ?

Accepted Answer

Ask the client if they are having pain

Question 8

The nurse is caring for an immediate post-op patient. Which of the following is a priority action ?

Accepted Answer

Assist the client when getting out of bed

Question 9

Which of the following age-related findings should be expected when doing a head & neck exam on an older client ?

Accepted Answer

Tooth loss, Glare intolerance, Thickened eardrums

Question 10

Muscle Grading is to test the strength of the muscle, rating 0-5. Which rating would be "strong, full ROM" ?

Accepted Answer

5

Question 11

A necessary safety precaution when ambulating a px is to :

Accepted Answer

have px wear well fitted rubber shoes/no slip socks

Question 12

If someone is experiencing Hyperthermia, you should keep the environment at what oF ?

Accepted Answer

70-80

Question 13

Sensory deficit would be defined as :

Accepted Answer

a deficit in one or more of the five senses

Question 14

Receiving stimuli at a rate and intensity beyond the brain&#x27;s ability to process the stimuli in a meaningful way ?

Accepted Answer

Sensory Overload

Question 15

While performing a physical exam on a px who has a right leg fracture, Which would be a pertinent negative finding ?

Accepted Answer

Px denies having pain when the area over the fracture is palpated

Question 16

A nurse is documenting findings following an exam on a new client. What should be included as part of a General Survey ?

Accepted Answer

Speech, Posture, Skin Lesions

Question 17

What is the average range for pupil size ?

Accepted Answer

3-7 mm

Question 18

Which of the following are functions/purpose of a dressing ?

Accepted Answer

Wound debridement, Prevent contamination, Promote Homeostasis

Question 19

A px arrives with a severe headache, what should the nurse do FIRST ?

Accepted Answer

Take the inital vital signs and then address the headache before health hx

Question 20

A type of Aphasia that causes someone to speak in a jumbled way. Ex.) "That shmoodle is too backar in the year"

Accepted Answer

Wernicke&#x27;s Aphasia

Question 21

Passive ROM exercises prevent ?

Accepted Answer

contractures

Question 22

The nurse determines the px radical pulse rate is 68. The apical pulse rate is 84. What is the px&#x27;s pulse deficit?

Accepted Answer

16

Question 23

What is a PERRLA assessment for ?

Accepted Answer

Pupils

Question 24

The nurse plans care for a client in a post-anesthesia care unit. Which of the following should the nurse assess first ?

Accepted Answer

Respiratory Status

Question 25

When a px has a left-sided cerebral hemorrhage, what may also be present?

Accepted Answer

Right-sided hemiplegia

Question 26

Which of the following should a nurse expect to find when preparing to auscultate or percuss a patient&#x27;s abdomen ?

Accepted Answer

High-pitches clicks, Tympany

Question 27

Placing the stethoscope over the left misclavicular line at the 5th-intercostal space is attempting to find the what ?

Accepted Answer

Apical heart rate

Question 28

A fever can be harmful if it exceeds what minimal temperature ?

Accepted Answer

102.2 oF

Question 29

A nurse documents at 5:00 PM, in military time this would be ?

Accepted Answer

1700

Question 30

A patient comes in with a chief complaint of a headache that would be considered "Onset", what does onset mean ?

Accepted Answer

the px&#x27;s headache came on suddenly

Question 31

A test used to evaluate hearing loss in one ear with a tuning fork ?

Accepted Answer

Rinne Test

Question 32

The Autonomic nervous system does what with the heart rate ?

Accepted Answer

Controls it

Question 33

Why does a wound bed need to stay moist ?

Accepted Answer

to support healing by enabling granulation tissue to grow

Question 34

During a Neuro exam, which of the following findings should be expected as changes associated w/ age ?

Accepted Answer

Some short-term memory decline, Slower light touch sensation, Some vision and hearing decline, Slower fine finger movement

Question 35

When assessing for a possible blod clot in the leg, which action should be taken FIRST ?

Accepted Answer

Visually inspect the leg

Question 36

A px who is actively bleeding is admitted to the ED. Which approach is BEST for the nurse to use to obtain a health hx ?

Accepted Answer

Briefly interview the px while obtaining VS

Question 37

When assessing the px&#x27;s abdomen, which action should the nurse take FIRST ?

Accepted Answer

Listen for bowel sounds

Question 38

When you hear "lub dub" for heart sounds, the second sound you hear is S2. What valves are closing ?

Accepted Answer

Pulmonary & Aortic

Question 39

Which of the following should be tested for assessing balance during a Neuro exam ?

Accepted Answer

Heel-to-toe walk, Romberg Test

Question 40

What kind of dressing is the best for maintaining homeostasis ?

Accepted Answer

Transparent Film

Question 41

What side of your hand do you use to quickly assess the surface temperature of a patient ?

Accepted Answer

Back of the hand

Question 42

Select All Apply : P(upilary Assessment)ERRLA. What do they stand for ?

Accepted Answer

Equal, light & accommodation, React, Round

Question 43

Which of the following require an immediate intervention when assessing the skin ?

Accepted Answer

Cyanosis

Question 44

During a comprehensive physical exam to assess the skin, What findings are expected ?

Accepted Answer

Numerous macules on the face darker than the surrounding skin color, Capillary refill in less than 3 secs, Thick skin on the soles of the feet

Question 45

Which scale is used to assess patients for risk of developing pressure injuries ?

Accepted Answer

Braden Scale

Question 46

Areas included in a General Survey :

Accepted Answer

Overall physical apperance, body structure, mobility

Question 47

A nurse is instructing a group of APs in measuring a px resp. rate, Which of the guidelines should the nurse include?

Accepted Answer

Observe one full respiratory cycle before counting the rate, Have the client rest an arm across the abdomen, Place the client in Semi-Fowler&#x27;s position

Question 48

What is the Snellen Chart used for ?

Accepted Answer

Clients who can not read, To screen for Myopia

Question 49

Assessing an older px w/ rectal bleeding, Nurse asks "Have you ever had a colonoscopy?" What type of assessment is it?

Accepted Answer

Focused Assessment

Question 50

When you hear "lub dub" for heart sounds, the first sound you hear is S1. What valves are closing ?

Accepted Answer

Tricuspid & Mitral

Question 51

An assessment of a px who has significant tenting on the skin of the forearm, what could be a cause of the tenting ?

Accepted Answer

Dimished skin elasticity, Dehydration, Loss of adipose tissue

Question 52

What evaluation criteria are included in the Braden Risk assessment ?

Accepted Answer

Sensory perception, Moisture, Friction & Shear, Mobility

Question 53

A px has a Temp - 101, Pulse - 114, RR - 22/min. They are restless w/ warm skin. Which interventions should be taken ?

Accepted Answer

Obtain culture specimens before initiating antimicrobials, Assist the client with oral hygiene frequently, Encourage the client to rest & limit activity

Question 54

When giving a change of shift report, you are expected to :

Accepted Answer

Provide an organized/concise descrption of the px status & anticipated need

Question 55

A nurse is instructing an AP about caring for a px w/ a low platelet count. Which is a priority for measuring VS?

Accepted Answer

"Do not measure the client&#x27;s temperature rectally"

Question 56

Encapsulated from deeper tissue w/ white-ish or clear fluid in it ?

Accepted Answer

Cyst

Question 57

Cloudy pupils disease ?

Accepted Answer

cataracts

Question 58

Which kind of saline is typically used for wound irrigation ?

Accepted Answer

.9% Sodium Chloride

Question 59

A nurse plans to complete a physical exam on an older px. Which adaptions to the exam technique should be included ?

Accepted Answer

Organize the sequence to minimize the position changes

Question 60

In the Braden scale, would a higher rating or lower rating indicate a severe risk for a pressure injury ?

Accepted Answer

Lower

Question 61

A type of Aphasia that omits small words, for ex.) a person would say "walk dog" instead of "I will walk the dog"

Accepted Answer

Broca&#x27;s Aphasia

Question 62

Assessing circulation, post-op on a px who had knee surgery, which of the following should be tested ?

Accepted Answer

Skin Color, Edema, Skin temperature

A lot of different stuff : T&P

Questions 62

A lot of different stuff : T&P

Questions 62