Vital Signs
What is considered a normal temperature range for an adult client?
What is a temperature range: 35.8◦ C- 37.3◦ C (96.4◦F - 99.1◦F)
A dark-skinned client appears ashen grey and dull. The nurse would identify this as.
What is pallor?
A nurse assesses a client using a Snellen chart. What is the purpose of this assessment?
What is visual acuity?
which one of these is the correct way to assess the pulse?
a. use two pads of your first two fingers to palpate
b. start the count from zero
c. count the beats for 2 minutes
d. assess for rate, rhythm, and regular
b. start the count from zero
Describe to a new graduate nurse how to appropriately palpate a radial pulse.
What is using pads of first 3 fingers to palpate number of beats for 30 seconds and multiplying by 2 (if regular) or 60 seconds if irregular?
Start your count with “zero” for the first pulse felt. The second pulse felt is “one,” and so on.
Linear crack with abrupt edges; extends into dermis; dry or moist.
What is Fissure?
The nurse is assessing an older adult client’s ear and sees the following findings: coarse wiry hairs in the ear canal, with white opaque tympanic membrane, and thick. The nurse would identify these findings as:
What is expected findings in the aging adult client’s ear?
A nursing student is performing a skin assessment on an adult client and notes multiple flat, purple-red lesions on the client’s forearms that do not blanch when pressure is applied. The lesions vary in size, with some measuring approximately 2 mm and others measuring 8 mm. Which of the following findings should the nursing student document?
A. Ecchymosis and erythema
B. Petechiae and purpura
C. Macules and patch
D. Vesicles and pustules
B. Petechiae and purpura
Upon entering the room, the nurse notices a client breathing 40 bpm? The nurse would interrupt this finding as.
What is tachypnea?
A nurse is assessing four patients. Which skin color change should be addressed first?
A. A patient with pallor noted in the conjunctiva
B. A patient with jaundice noted in the sclera
C. A patient with cyanosis of the mucous membranes and nail beds
D. A patient with erythema over the sacral area
What is a patient with cyanosis of the mucous membranes and nail beds
After assessing a patient with a head injury, the nurse educates the caregiver to seek immediate medical attention if the patient experiences a change in loss of consciousness. The nurse understands this is associated with what condition?
What is concussion?
A new grad nurse asks the preceptor to explain systolic, diastolic and pulse pressure. The nurse would describe each as:
Blood pressure (BP) is the force of the blood pushing against the side of its container, the vessel wall. The strength of the push changes with the event in the cardiac cycle. The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction. The pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume
During a routine check, the nurse notes that a client’s pulse oximetry reading is 88%. What is the priority nursing action?
A) Administer oxygen as prescribed
B) Document the finding
C) Recheck the pulse oximetry after 10 minutes
D) Assess the client’s level of consciousness
What is administer oxygen as prescribed?
A nurse is performing a skin, hair, and nails assessment on a 65-year-old patient. Which of the following findings would be considered a normal age-related change?
A. thickened, yellow toenails
B. Increased hair growth on the arms and legs
C. Smooth, evenly pigmented skin with no lesions
D. Decreased skin elasticity and wrinkling
What is decreased skin elasticity and wrinkling?
A nurse is performing a HEENT assessment on a 45-year-old client. During the assessment, the client reports experiencing a sensation of fullness in the ears and difficulty hearing. What is the most appropriate follow-up question the nurse should ask to further assess the client's condition?
A) "Have you had any recent colds or sinus infections?"
B) "Do you have a history of ear infections?"
C) "Have you been exposed to loud noises recently?"
D) "Are you experiencing any dizziness or vertigo?"
What is "have you had any recent colds or sinus infections?"
A nursing student is completing a health assessment on a client with suspected hypothyroidism. Which assessment finding would the student expect to identify?
A. Warm, moist skin and increased appetite
B. Weight loss, diarrhea, and restlessness
C. Exophthalmos and heat intolerance
D. cold intolerance, fatigue, and dry skin
D. cold intolerance, fatigue, and dry skin
The nurse is teaching a client about the importance of monitoring blood pressure. Which statement by the client indicates a need for further teaching?
A) “I should avoid caffeine before my blood pressure is taken.”
B) “I can take my blood pressure immediately after exercise.”
C) “It’s important to rest for a few minutes before the measurement.”
D) “I will use the same arm for each measurement.”
What is “I can take my blood pressure immediately after exercise.”
The nurse is assessing several skin lesions. Which would the nurse recognize as the priority for referral for skin biopsy?
A. Asymmetrical; tan with a defined border; 3mm
B. Asymmetrical; brown with a black, irregular border; 6.5 mm
C. Symmetrical; dark brown with a regular border; 7 mm
D. Symmetrical; brown with an irregular border; 5 mm
What is asymmetrical; brown with a black, irregular border; 6.5 mm?
A nurse is performing the whisper test to assess a client’s hearing. Which of the following actions should the nurse take to ensure accurate results?
A) Stand directly in front of the client and whisper softly.
B) Cover the client’s ear opposite to the one being tested.
C) Use a loud voice to ensure the client hears the whisper.
D) Whisper a series of numbers to assess auditory comprehension.
What is cover the client’s ear opposite to the one being tested?
A nursing student is reinforcing teaching with a client about maintaining a healthy integumentary system. Which client statements indicate an understanding of appropriate skin care and risk reduction strategies? Select all that apply.
A. “I should avoid prolonged sun exposure between 10 AM and 3 PM.”
B. “I will wear a broad-brimmed hat and sunglasses when outdoors.”
C. “Using sunscreen with an SPF of 15 is enough protection.”
D. “I should check my skin regularly for changing moles.”
E. “Smoking can contribute to premature wrinkles, so quitting is important.”
F. “Staying hydrated and using moisturizer can help maintain healthy skin.”
G. “Unsanitary tattooing and piercings can increase my risk for infection.”
H. “I only need to see a dermatologist if I notice a problem.”
A. “I should avoid prolonged sun exposure between 10 AM and 3 PM.”
B. “I will wear a broad-brimmed hat and sunglasses when outdoors.”
D. “I should check my skin regularly for changing moles.”
E. “Smoking can contribute to premature wrinkles, so quitting is important.”
F. “Staying hydrated and using moisturizer can help maintain healthy skin.”
G. “Unsanitary tattooing and piercings can increase my risk for infection.”