patient’s visual acuity is assessed as 20/40 in both eyes using the Snellen chart. This means:

The patient has less than normal vision.

What can contribute to a false high reading of blood pressure?

Arm position is below heart level

An adult patient’s pulse is 140 beats/min. What should the nurse do next?

Report the rate to the primary care provider.

A student nurse is learning to assess blood pressure. What does the blood pressure measure?

Force of blood against arterial walls

nurse is assessing a patient’s eyes for accommodation. What actions would the nurse perform?

Hold straight object 4"-6" from bridge of patient’s nose.

A nurse is documenting a BP of 120/80 mm Hg. The nurse interprets the 120 to represent:

The highest pressure present on arterial walls (vent. con)

What technique facilitates accurate auscultation?

The chestpiece of the stethoscope is sealed against the skin

The patient's radial pulse is weak and thready. The next action of the nurse is to

compare findings to previous findings & opposite extremity.

A nurse understands proper technique for measuring radial pulse when she takes which actions?

Helps the patient to a supine or sitting position.

nurse is palpating the breast of a woman during an assessment. Which technique is correct?

starts at the tail of Spence & moves in ↑ smaller circles

Which of the following statements shows that a nurse correctly understands infection control?

The most important action to prevent infection=hand hygiene.

Which actions will result in an inaccurate BP reading? Select all that apply

Obtaining BP right after the patient has entered the room, Pumping the cuff 10 mm Hg above the palpated systolic BP, Using a BP cuff 80% of the arm circumference

Which of the following vitals would be considered abnormal?

An adult with a blood pressure of 136/82

Which of the following is the rationale for nurse 2 reassess the patient's pain after treatment

To establish the efficacy of medication

Which of the following findings during general survey indicates a change in mental status? SATA

Rapid speech, Lethargy, Disheveled appearance

more common in nurses & in frequently hospitalized patients

patient has BP of 130/90 mmHg when visiting a clinic. Nurse should recommend what?

Follow-up measurements of blood pressure

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6001 Module 2

72 termsStudBud Administration14 plays

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Questions 72

Answers

1
Percussion: what body part would you hear soft intensity/high pitch/short duration/dull quality
lungs
stomach
bone
liver
2
The nurse notes an irregular radial pulse in a patient. Further evaluation includes assessing
for a pulse deficit.
for diminished peripheral circulation.
the brachial pulse.
the carotid pulse.
3
Which is NOT considered equipment for advanced techniques used during a complete assessment?
stethoscope
tuning fork
goniometer
reflex hammer
4
patient’s visual acuity is assessed as 20/40 in both eyes using the Snellen chart. This means:
The patient has less than normal vision.
The patient has double vision.
The patient can see twice as well as normal.
The patient has normal vision.
5
What can contribute to a false high reading of blood pressure?
Environment is noisy
Stethoscope was not over the brachial artery
Arm position is below heart level
Cuff was deflated too quickly
6
An adult patient’s pulse is 140 beats/min. What should the nurse do next?
Record the information.
Check the blood pressure.
Check the pulse again in 2 hours.
Report the rate to the primary care provider.
7
14. True or False: gender, ethnicity, and acculturation influence pain behavior and expression
true
false
8
What error may result from a cuff that is too large or too small?
An incorrect reading
Injury to the patient
Loss of Korotkoff sounds
Prolonged pressure on the arm
9
Which statements accurately describe factors that affect blood pressure?
all of the above
BP tends to be lower in prone or supine position.
Women usually have lower BP than men until menopause.
Blood pressure is usually lowest on arising in the morning.
10
A student nurse is learning to assess blood pressure. What does the blood pressure measure?
Flow of blood through the heart
Force of blood against venous walls
Force of blood against arterial walls
Flow of blood through the circulation
11
patient describes a “cramping” pain in abdomen. This patient is experiencing what type of pain?
referred
cutaneous
visceral
somatic
12
Nurse is doing a functional assessment on a new patient. Which questions would the nurse ask?
Do you manage your own finances?
all of the above
Do you prepare your own meals?
Are you able to dress yourself?
13
nurse is assessing a patient’s eyes for accommodation. What actions would the nurse perform?
Hold straight object 4"-6" from bridge of patient’s nose.
Hold a finger about 6″-8″ from the bridge of patient’s nose.
darken the room
Bring penlight from side of patient’s face
14
A nurse is documenting a BP of 120/80 mm Hg. The nurse interprets the 120 to represent:
The highest pressure present on arterial walls (vent. con)
The lowest pressure present on arterial walls (vent. relax)
The rhythmic distention of the arterial walls
Diff. btwn pressure on art. walls w/ vent. cont. & relax.
15
What technique facilitates accurate auscultation?
Earpieces of stethoscope are positioned to point toward back
Diaphragm of stethoscope is used for low-frequency sounds
The tubing of the stethoscope is long and dark in color
The chestpiece of the stethoscope is sealed against the skin
16
In which cases would taking a rectal temperature be used?
An older patient who is post myocardial infarction
A newborn who has hypothermia
A teenager who has leukemia
A child who has pneumonia
17
nurse asks patient to raise eyebrows, smile, and show the teeth to assess which cranial nerve?
facial
vagus
optic
olfactory
18
What can contribute to a false low reading of blood pressure?
Legs are crossed
Patient’s arm is at heart level
BP is taken after exercise
Cuff is too large
19
The patient's radial pulse is weak and thready. The next action of the nurse is to
transfer the patient to a critical care unit.
compare findings to previous findings & opposite extremity.
assess vital signs every 15 minutes
notify the primary care provider.
20
A patient says that his pain worsens with weight bearing activity. A nurse would consider this:
a functional pain goal.
quality/description.
an alleviating factor.
an aggravating factor.
21
The patient has pain of a short duration with an identifiable cause. This is referred to as
chronic pain
acute pain
complex pain
neuropathic pain
22
The patient is complaining of abdominal pain. What technique is used to form overall impression
auscultation
direct percussion
light palpation
deep palpation
23
A nurse understands proper technique for measuring radial pulse when she takes which actions?
Helps the patient to a supine or sitting position.
Has the patient’s arm elevated.
Counts the pulse for 15 seconds and multiplies by 4.
Applies significant pressure to the pulse site.
24
Which of the following indicators would signify to the nurse that a patient is having pain?
Falling asleep
rubbing a body part
facial relaxation
Relaxed body position
25
One dimensional pain assessment on patient..The nurse is measuring the ______ of the pain.
duration
intensity
location
all of the above
26
standard precautions:
Recognize that transmission-based precautions are common.
Include the use of gowns, gloves, & masks with all patients.
are used on every patient
State that hand gel is used for Clostridium difficile inf.
27
nurse is palpating the breast of a woman during an assessment. Which technique is correct?
starts at the tail of Spence & moves in ↑ smaller circles
palpates from the periphery->areola in counterclockwise dir.
uses palms of the hands to gently compress breast tissue
starts at inner edge of breast and palpates ↑/↓ breast
28
nurse hears coarse/low-pitched/continuous sounds on expiration that clear when coughing.
Bronchovesicular breath sounds
Vesicular breath sounds
adventitious breath sounds
Bronchial sounds
29
To identify the location of pain, the nurse asks the patient
to rate the intensity of the pain on a scale from 0 to 10.
to point to the painful area.
how long he or she has had the pain.
to describe the quality of pain.
30
Patients are at risk for complex regional pain syndrome if:
They have had surgery or a crushing-type injury
They start to report neuropathic pain
all of the above
Their pain is undertreated or completely untreated
31
which of the following types of patients is the nurse most likely to use the FACES pain scale?
patients with dementia
children
unconscious patients
older adults
32
Which of the following is an example of inspection?
pink skin
abdomen tympanic
lungs clear
Heart rate and rhythm clear
33
Adult patient’s temp is (99.5°F). What term would the nurse use to report this temperature?
afebrile
hypertension
hypothermia
febrile
34
22 yr.o man V/S: T 37.2°C, po; P142 bpm; R 20 breath/min; BP 100/64 mm Hg. He is experiencing:
tachycardia
auscultory gap
eupnea
asystole
35
Pain/depression/insomnia/mask-like facial expression/frequent position changes. Patient has:
chronic regional pain syndrome
chronic pain
acute pain
neuropathic pain
36
V/S: T 36.6°C, temp; P72 bpm, reg., 2+; R18 breaths/min, reg., no acces m. use; BP 142/92 mmHg.
respirations
pulse
BP
temperature
37
Nurse notices yellow tinted skin on patient w/ liver disease. What would the nurse document?
pallor
jaundice
cyanosis
erythema
38
Tympany is a percussion sound commonly located in the:
abdomen
upper arm
thigh
thorax
39
Which of the following statements shows that a nurse correctly understands infection control?
The most important action to prevent infection=hand hygiene.
Wearing fake nails has no effect on spreading infections
I only need to use hand sanitizer before/after doing cares.
Wearing gloves always prevents infections.
40
Which actions will result in an inaccurate BP reading? Select all that apply
Obtaining BP right after the patient has entered the room
Pumping the cuff 10 mm Hg above the palpated systolic BP
Using a BP cuff 80% of the arm circumference
Asking the patient to hold out his/her arm above heart level
41
Nurse routinely visits patient's home to take VS, then records data in chart. Assessment?
Comprehensive
Emergency assessment
Focused assessment
Ongoing partial assessment
42
Which of the following would prompt the nurse to take an oral temperature?
Patient is a mouth breather
Patient is alert and aware
Patient has recently had oral surgery
Patient is an infant
43
For what circumstance would the nurse use to assess pain using the McGill Pain Questionnaire?
verbal description
pain goal
alleviating factors
functional status goal
44
Which of the following vitals would be considered abnormal?
A 72-year old whose pulse rate is 42 bpm
An adult whose respiratory rate is 20 bpm
An adult with a blood pressure of 136/82
An adolescent whose pulse rate is 70 bpm
45
Which of the following is the rationale for nurse 2 reassess the patient's pain after treatment
To pinpoint the pain's location
To measure the pain's duration
To make changes to the patient's pain goal
To establish the efficacy of medication
46
Which of the following tools would a nurse use to perform a multidimensional pain assessment?
Visual analogue scale
Brief Pain Inventory
Numeric Pain Intensity
Verbal descriptor
47
what type of breath sound would the nurse document for high-pitched continuous sound?
stridor
crackles
wheezes
Rhonchi
48
Which of the following findings during general survey indicates a change in mental status? SATA
Rapid speech
Asymmetrical movements
Lethargy
Disheveled appearance
49
latex allergies:
always result in anaphylactic reactions and shock.
more common in nurses & in frequently hospitalized patients
cannot be caused by equipment such as a stethoscope.
can be reduced by moisturizing the hands after washing.
50
patient has BP of 130/90 mmHg when visiting a clinic. Nurse should recommend what?
Follow-up measurements of blood pressure
No action, b/c the nurse considers this is due to anxiety
Immediate treatment by a physician
A change in dietary intake
51
Type of skin lesion with a palpable solid mass measured at 1cm?
plaque
patch
macule
bulla
52
Patient hypersensitive to touch&pressure as result of inflammatory process from painful stimuli
windup
Peripheral sensitization
Neuronal plasticity
Central sensitization
53
inspection:
all of the above
Begins as soon as you walk into the patient’s room
Continues through each body system
Includes observing for levels of discomfort/anxiety
54
When assessing the child, the nurse makes the following adaptation to the usual techniques:
A pediatric stethoscope is used for better contact.
The room is full of toys for play.
The child is seated away from the parent.
The child is undressed, including the diaper.
55
Which organs or body areas does the nurse auscultate as part of the admitting assessment?
Hearts, lungs, and abdomen
Abdomen, flank, and groin
Neck, jaw, and clavicle
Kidneys, bladder, and ureters
56
the intensity of a tympanic tone on a patient's abdomen sounds like:
moderate
loud
soft
very loud
57
patient has severe abdominal pain. Nurse wouldn't be surprised to find what assessments?
An increase in the pulse rate
A decrease in body temperature
An increase in respiratory depth
A decrease in blood pressure
58
2 nurses took an apical-radial pulse and note a diff. in pulse rate of 8bpm. Document this as?
Ventricular rhythm
pulse deficit
Heart arrhythmia
Pulse amplitude
59
Adult patients may have variations in pulse rates with
exercise
heat
respirations
food intake
60
Which patients would the nurse document as having a normal V/S (select all that apply)
A 4-month old infant whose temperature is 38.1°C (100.5°F)
A 74-year old with a blood pressure of 184/92
A 9-year old whose temperature is 39°C (102.2°F)
A 3-year old whose blood pressure is 118/80
61
A patient is having dyspnea. What would the nurse do first?
Elevate the foot of the bed
Elevate the head of the bed
Remove pillows from under the head
take the blood pressure
62
Which of the following patients should not have a temperature measured orally?
A 62-year-old woman who has had oral surgery
An 84-year-old woman with diarrhea
A 45-year-old man with chest pain
A 30-year-old patient with an earache
63
Which of the following is a barrier to pain assessment?
Nurse has difficulty accepting patient's selfreport as valid
Nurse picks treatment that'll posit. affect patient's care
The nurse believes that patients suffer if under medicated.
Nurse focuses on pain relief as primary end to assessment
64
patient has IV in right arm. How should nurse take blood pressure?
Take the blood pressure in the left arm
Use the smallest possible cuff
Report inability to take the blood pressure
Take the blood pressure in the right arm
65
Which of the following is NOT a part of the general survey?
gait
hygeine
facial symmetry
heart rate
66
Which actions would the nurse perform when using the technique of palpation during assessment?
The nurse checks a patient’s lymph nodes for swelling.
nurse uses a stethoscope to listen to heart sounds.
nurse compares patient’s bilateral body parts for symmetry.
The nurse taps a patient’s body to check the organs.
67
Which of the following is an appropriate use of gloves?
Gloves are worn during anticipated contact with intact skin
Are removed when going from clean to contaminated areas.
Removed when assessing the back of an incontinent patient.
Are worn during anticipated contact w/ body secretions.
68
What is the correct order of a physical assessment on the abdomen?
Palpation, auscultation, inspection, percussion
Auscultation, inspection, percussion, palpation
Inspection, auscultation, percussion, palpation
Palpation, auscultation, inspection, percussion
69
An auscultatory gap is defined as
the difference between the apical and radial pulse.
a drop in the SBP of 15 mm Hg or more with position change.
SBP minus the DBP.
a period of silence heard between Korotkoff sounds.
70
nurse rates patient as M2 for motor response in FOUR Coma Scale. What does this # represent?
No response to pain
Localizing to pain
Extension response to pain
Flexion response to pain
71
febrile patient loses body heat through perspiration...Ex. of what mechanism of heat loss?
radiation
evaporation
conduction
convection
72
Which action describes a step the nurse would take when performing assessment of eye movements?
Move penlight in a circular motion in front of the eyes.
Ask the patient to sit about 3 feet away facing the nurse.
Ask the patient to cover one eye with a hand or index card.
keep penlight 1 foot from patient's face

6001 Module 2 Flashcards | StudBud