What's this I have found?
THE NURSE WALKS INTO A CLIENT'S ROOM AND FINDS THAT THE CLIENT IS DISORIENTED TO TIME AND PLACE BUT IS AWAKE AND RESPONSIVE. WHAT TERM BEST DESCRIBES THIS PATIENT?
confused a/o x 1
DURING AN ASSESSMENT OF THE CRANIAL NERVES, A PATIENT TELLS THE NURSE OF NOT BEING ABLE TO TASTE SWEET OR SALTY FOODS. THE NURSE SHOULD FOCUS ADDITIONAL ASSESSMENT ON WHICH CRANIAL NERVE?
VII (7)
DURING AN ABDOMINAL ASSESSMENT, THE NURSE ELICITS TENDERNESS ON LIGHT PALPATION IN THE RIGHT LOWER QUADRANT. THE NURSE INTERPRETS THAT THIS FINDING COULD INDICATE A DISORDER OF WHICH OF THESE STRUCTURES?
appendix
A NURSE NOTICES THAT A PATIENT HAS ASCITES, WHICH INDICATES THE PRESENCE OF:
fluid
You are admitting a new patient into the nursing home, what type of history are you going to gather?
comprehensive health assessment
T or F. Normal lymph nodes should be firm, fixed and tender
false
THE NURSE PLACES A KEY IN THE HAND OF A PATIENT AND HE IDENTIFIES IT AS A PENNY. WHAT TERM WOULD THE NURSE USE TO DESCRIBE THIS FINDING?
stereognosis
WHICH STRUCTURE IS LOCATED IN THE LEFT LOWER QUADRANT OF THE ABDOMEN?
Sigmoid Colon
UPON EXAMINATION OF A PATIENT ADMITTED TO THE HOSPITAL WITH BRONCHITIS, THE NURSE NOTES A LOW-PITCHED, SNORING SOUND THAT IS MORE PROMINENT ON EXPIRATION. THIS FINDING IS CONSISTENT WITH THE SOUND DESCRIBED AS?
Rhonchi
What does the "T" stand for in the OLDCART mnemonic?
treatment
A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time?
document this as a normal finding
AN OLDER PATIENT WITH A CHANGE IN MENTAL STATUS IS CLENCHING THE JAW CLOSED TO AVOID TAKING A PRESCRIBED ORAL MEDICATION. THE PATIENT IS DEMONSTRATING THE MOTOR FUNCTION OF WHICH CRANIAL NERVE?
trigeminal V
Your patient expresses pain in the RUQ with deep palpation. This is a positive Murphy's test indicitive of?
choleysistitis
Pain-related to tissue damage is termed?
somatic pain
What part of the stethoscope is used to check for murmurs?
bell
A PATIENT HAS BEEN ADMITTED TO A HOSPITAL AFTER THE STAFF IN THE NURSING HOME NOTICED A PRESSURE ULCER IN HIS SACRAL AREA. THE NURSE EXAMINES THE PRESSURE ULCER AND DETERMINES THAT IT IS A STAGE II ULCER. WHICH OF THESE FINDINGS IS CHARACTERISTIC OF A STAGE II PRESSURE ULCER?
open blister-like area with a red-pink wound bed
A nurse noticed the presence of nystagmus while assessing the clients extraocular movements. Describe what this is.
a condition that causes involuntary, rhythmic eye movements that a person has no control over
What sound is in 2nd sternal border left side of heart?
pulmonic
What is the breath sounds are heard over the periphery of the lungs?
vesicular
What is the effect of pain on the vital signs?
increased: HR, RR, BP
Which answer puts priorities in the correct order?
BP 70/40, pain, RR 20
RR20, pain, BP 70/40
pain, BP 70/40, RR20
BP 70/40, RR20, pain
Describe the confrontation test.
Use cards to cover same eye, stand 1-2 feet apart, wiggle fingers in the superior, lateral, nasal, and inferior positions and ask the patient to say now when he or she sees the fingers come into view.
An diffusely enlarged thyroid gland, such as in hyperthyroidism.
An diffusely enlarged thyroid gland, such as in hyperthyroidism.
The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?
Objective
What is the number of minutes bowel sounds are considered absent?
What is the number of minutes bowel sounds are considered absent?