Skin/HEENT
Lungs/Heart/PV
Abdomen
Musculoskeletal
Neurological
100
When initiating a physical examination, which action should the nurse take first? a. Review of the patient’s prior medical records b. Gather admission health history forms c. Assess the patient’s vital signs d. Perform light and deep palpation for fluid
c. Assess the patient's vital signs
100
Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. “What do you do for a living? Can you describe your work environment?” b. “Is there a family history of heart disease, cancer, high blood pressure, or stroke?” c. “When was your last annual physical? What immunizations did you receive at that time?” d. “Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?”
d. “Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?”
100
Which action by a patient marks the beginning of the physical assessment process? a. Redressing after a physical examination b. Breathing normally during auscultation c. Greeting the nurse in the examination room d. Sharing work environment information
c. Greeting the nurse in the examination room
100
If the nurse discovers that a patient’s right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid c. Perform passive range of motion to promote flexibility d. Inspect the patient’s left elbow to compare its appearance
d. Inspect the patient’s left elbow to compare its appearance
100
Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient e. Music preference of the patient
a, b, c, d
200
While assessing the throat of a child, the nurse documents the tonsils as 3+. What does this indicate?
tonsils touch the uvula
200
The nurse is auscultating a patient’s heart sounds. Which area is best for hearing the sound of the mitral valve?
Fifth left intercostal space at the midclavicular line
200
The nurse observes rebound tenderness in the abdomen of a patient. What condition does this finding indicate?
appendicitis
200
Which food should the nurse include in the patient’s diet to increase calcium levels? Select all that apply. a. Milk b. Apple c. Banana d. Yogurt e. Cheese
a, d, e
200
While assessing neurologic function, the nurse assess the muscle of mastication by palpating the temporal and masseter muscles as the person clenches the teeth. What cranial nerve is this?
CN V- Trigeminal
300
A patient presents with an itchy scalp, please demonstrate and state what you might find on this patient. Bonus: 50pts- what might it be?
normal findings: hair evenly distributed, no lesions, no parasites, hair is thick. abnormal findings (this patient): parasites, redness, flaking skin Bonus: Pediculosis Capitis (head lice)
300
Patient has pneumonia. Complete appropriate assessment (describe normal) and explain what you might find in this patient.
Inspect: thorax is symmetric, ribs slope downwards, AP to transverse is 1:2, no tripoding, relaxed Palpation: chest expansion is symmetric, what is RR, no masses, spine at midline, Auscultation: Listens to lungs and able to explain normal (Bronchial, Bronchiavesicular, and vesicular) This patient: crackles- fluid build up in the lungs.
300
Which statements would the nurse include when teaching an aging adult about prevention of constipation? Select all that apply. a. "Include high-fat food in the diet." b. "Include low-fiber foods in the diet." c. "Do not retain stool deliberately." d. "Participate in physical exercise." e. "Drink an adequate quantity of water."
c, d, e.
300
A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? a. mopping her floors b. brushing the back of her hair c. fastening her bra behind her back d. reaching into a cabinet above her sink
c. fastening her bra behind her back
300
The nurse asks the patient to close the eyes and then places a paper clip on the patient’s palm. The patient is asked to recognize the object. Which test is the nurse performing? a. Extinction b. Stereognosis c. Graphesthesia d. Discrimination
b. stereognosis
400
Child comes into clinic complaining of ear pain. Please complete appropriate assessment (state normals) and what might you see if child has pain in their ears.
Pinna skin intact with no masses, lesions. No tenderness noted with palpation. This patient: cerumen built up in ears. Unable to pass whisper test in right ear.
400
Complete a PV assessment.
Looking at jugular veins with the client on bed with head of bed at 30-45 degree angle to assess for right sided heart failure (distention)- blood flow backs up to vena cava. Observe for any obvious signs of palpitations (bounding pulse) Look for edema: accumulation of fluid in the tissues most often from impaired venous return (right sided heart failure- dependent edema)—assess for discoloration and location. Inspect peripheral veins for varicosities (places where you can see veins, i.e. varicose veins), redness, and swelling Check pulse and grade them.
400
Complete an abdominal assessment
Auscultate before percussion. Normals listed, CVA done.
400
A football player complains of knee pain. Complete an appropriate assessment.
Normals stated. Bonus: what would a click in the knee indicate? 50pts.
400
Name the cranial nerves in order and perform cranial nerve III, IV and VI.
Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Acoustic, Glossopharyngeal, Vagus, Spinal accessory, Hypoglossal. PERRLA, no nystagmus, cardinal fields of gaze,
500
Teach how to perform a self skin assessment
examine their skin using the ABCDE rule. A is asymmetric, B is borders, C is consistency of color, D is diameter greater than 6mm, and E is elevation/evolution. It is important to teach pt to undress completely (before shower) and look for abnormal moles or new moles.
500
Teach what is happening when you hear S1 and S2.
S1: aka LUB- closure of the mitral and tricuspid valve (Contraction) S2: aka DUB- closure of the aortic and pulmonic valves (Relaxation)
500
Explain what you might give your patient who is on a pureed diet. BONUS: 50 pts. what kind of patient might be on this diet
made up of food that require no chewing. Pudding, mashed bananas, ensure, etc. Bonus: dysphagia
500
Describe the 5 different grades of muscle testing.
5- full ROM against gravity, full resistance 4- full ROM, against gravity, some resistance 3- full ROM with gravity 2- full ROM with gravity eliminated (passive) 1- slight contraction 0- no contraction
500
Explain the difference between efferent and afferent messages.
afferent (sensory): to CNS from sensory receptors efferent (motor): from CNS out to muscles and glands
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