Unit 1-3
1. Which of the following best describes subjective data?
A. Measurable signs collected by the nurse
B. Information provided by the client about their experience
C. Observations made during physical inspection
D. Data verified by diagnostic testing
B. Information provided by the client about their experience
Which of the following is subjective integumentary data?
A. Skin temperature warm to touch
B. Client reports new mole on left shoulder
C. Skin turgor <2 seconds
D. Nails pink and smooth
B. Client reports new mole on left shoulder
The Glasgow Coma Scale assesses:
A. Cranial nerves
B. Level of consciousness and response
C. Balance and coordination
D. Pain perception
B. Level of consciousness and response
How long do we listen for in 1 quadrant to determine if bowel sounds are "Absent"
5 mins
What is an accurate description of the term "Adduction"
A. Moving a limb away from the midline of the body
B. Moving a limb toward the midline of the body
C. Moving a body part forward and parallel to the ground
D. Moving the arm in a circle around the shoulder
B. Moving a limb toward the midline of the body
. Which finding would be considered abnormal during vital sign assessment?
A. Pulse 78 bpm
B. Respiratory rate 16 per minute
C. Blood pressure 90/50 mmHg
D. Temperature 36.7°C
C. Blood pressure 90/50 mmHg
When assessing a darker-skinned client for pallor, the nurse should:
A. Inspect the sclera, conjunctiva, and mucous membranes
B. Focus on skin color of the arms
C. Compare with a photograph
D. Check for yellow undertones on the chest
A. Inspect the sclera, conjunctiva, and mucous membranes
Subjective respiratory data includes:
A. Client reports shortness of breath when climbing stairs
B. Respiratory rate 20 breaths per minute
C. Clear breath sounds
D. Chest symmetrical
A. Client reports shortness of breath when climbing stairs
Where do we listen to first when auscultating bowel sounds and what direction are we moving? What are some contraindications to this?
RLQ and move clockwise unless that quadrant is painful then we assess it last.
When assessing muscle strength using a 0-5 grading method, what score would we grade "Full ROM, against gravity, some resistance"
4
The Braden Scale is used to assess:
A. Risk for pressure injury development
B. Pain level
C. Degree of dehydration
D. Nutritional status
A. Risk for pressure injury development
The “E” in the ABCDE rule for skin lesions stands for:
A. Elevation
B. Edge
C. Enlargement
D. Erythema
A. Elevation
Abnormal AP diameter (Barrel) can be described as what ratio?
A. 2:1
B. 1:2
C. 1:1
D. 2:3
C. 1:1
Which finding is abnormal?
A. Regular rhythm
B. No jugular vein distention
C. Edema in both ankles
D. Capillary refill brisk
C. Edema in both ankles
The nurse determines the type of assessment based on:
A. Client’s condition and reason for visit
B. Nurse’s preference
C. Physician’s orders only
D. Time of day
A. Client’s condition and reason for visit
When assessing an older adult, which adaptation is most appropriate?
A. Conducting the assessment rapidly to minimize fatigue
B. Ignoring minor complaints
C. Allowing extra time and ensuring proper lighting and hearing aids are used
D. Performing the assessment in a noisy environment
C. Allowing extra time and ensuring proper lighting and hearing aids are used
The Snellen chart assesses:
A. Near vision
B. Peripheral vision
C. Distance visual acuity
D. Depth perception
C. Distance visual acuity
Bronchial Breaths sounds can be auscultated where?
A. Sternal area
B. Tracheal area
C. Peripheral lung fields
D. Mid-scapula area
B. Tracheal area
True or False:
Dangling the legs help alleviate pain for peripheral arterial disease
TRUE
What type of database is most appropriate for an individual that was admitted to a long term care facility?
A. Episodic
B. Emergency
C. Follow Up
D. Complete
D. Complete
Which of the following is an example of a 2nd level priority?
A. Increased Blood pressure and Pulse
B. Increased confusion
C. Diabetic Teaching
D. Discharge
B. Increased Confusion
Which of the following would be abnormal lymph node findings?
A. Small, soft, mobile, non-tender nodes
B. Firm, fixed, and enlarged nodes
C. Nonpalpable nodes
D. Symmetrical node size
B. Firm, fixed, and enlarged nodes
List 2 assessments we can do for Cranial Nerve V:
Sensory: Light touch sensation on different areas of the patient's face.
S2 occurs with the closure of what?
A. AV Valves
B. Pulmonic
C. Semilunar Valves
D. Tricuspid
C. Semilunar Valves
A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority?
A) Ineffective self–health management
B) Risk for infection
C) Impaired gas exchange
D) Readiness for enhanced spiritual well-being
C) Impaired gas exchange