Techniques & Equipment
The part of the stethoscope nurses use to auscultate the heart sounds.
What is the diaphragm of the stethoscope
How do nurses assess a patient’s pain?
What is asking the patient to rate the pain being experienced
This lobe of the brain is responsible for processing visual information.
What is the occipital lobe?
What does the S2 heart sound represent?
The closure of the aortic and pulmonic valves
This high-pitched sound heard during inspiration is caused by airway obstruction.
What is stridor
To test deep tendon reflexes, the nurse uses which instrument?
What is a reflex hammer
A patient with a partial small bowel obstruction describes the pain as “cramping, off-and-on pain that spreads over my stomach.” What type of pain is this patient experiencing? Referred, Phantom, Somatic or Visceral
What is visceral
This scale is commonly used to assess the level of consciousness in patients with suspected brain injuries.
What is the Glasgow Coma Scale?
Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border?
Tricuspid
A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination?
Distant to absent breath sounds over left lung
While assessing a patient’s lower extremities, the nurse suspects the lower extremities feel cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the temperatures of the lower extremities with the upper extremities?
What is the back of your hand
A patient who had extensive surgery asks the nurse for pain medication for a pain of 9 on a scale of 0 to 10. The nurse completes an assessment of this patient’s pain and agrees to give pain medication. When the nurse returns to the patient with the ordered intravenous pain medication, she notices the patient’s eyes are closed and he appears to be sleeping. What is the nurse’s appropriate action at this time?
What is give the medication as ordered and agreed to.
A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection?
What is clear drainage from ears and nose
While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?
A raspy machine-like or blowing sound heard during auscultation; a murmur that can develop after rheumatic heart disease.
This chronic disease is characterized by inflammation and narrowing of the airways, causing wheezing and shortness of breath.
What is asthma
A 75-year-old man has a history of hypertension and was recently prescribed a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his BP?
Assess BP and pulse with the patient in the supine, sitting, and standing positions.
the process of pain perception and it involves transduction, transmission, perception, and modulation.
What is nociception
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. With these findings, which area of the brain would concern the nurse?
Cerebellum
A nurse determines that a patient has a heart rate of 42 beats/min. What might be a cause of this heart rate?
a. Left ventricular hypertrophy
b. Atrial bradycardia
c. A well-conditioned heart muscle
d. Sinoatrial (SA) node failure
What is SA node failure
A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient's chest pain?
What is costochondritis
What assessment data do nurses obtain through striking a hand directly against the flank or costovertebral angle of a patient’s body?
What is kidney tenderness
Acronym for symptom assessment
What is onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, self-treatment, and severity. OLDCARTSS
A nurse assessing a patient who had a cerebrovascular accident involving the Broca area suspects expressive or nonfluent aphasia. What communication abilities does the nurse anticipate from this patient?
They can understand words but cannot formulate words.
This term refers to the resistance the heart must overcome to pump blood through the body
What is afterload?
This type of percussion sound is heard over air-filled areas of the lungs.
What is resonance?