Show:
Tacos
Burger
Sushi
Pizza
Cake
100
While counting apical pulse on 16 yr old, nurse notes irregular rhythm - speeds up on inspiration, slows on exhalation - What is the nurse's response?
NO response - normal!
100
Preparing to do an otoscopic exam on a 2 yr old. What is correct procedure?
Pull pinna down
100
In using the ophtalmoscope to assess a pt's eyes the nurse notes a red glow in the pupils. What does the nurse do?
Consider it a normal reflection of the light off the inner retina
100
While auscultating heart sounds, the nurse hears a murmur What should be used to assess it?
The bell of the stethoscope
100
Which technique uses sense of touch?
palpation
200
65 yr old w/ emphysema & bronchitis, what is expected on examination of hands?
clubbing of the nails
200
A nurse notes pt has ascites, which indicates:
There is fluid in the peritoneal cavity
200
The nurse is testing a pt's visual accommodation, which refers to:
Pupillary constriction when looking at a near object
200
What is a bruit?
Soft, whooshing sound caused by turbulence best heard w/ bell of stethoscope
200
Pt tells nurse he is very nervous and that he "feels hot". This type of data would be:
subjective
300
The most important technique when auscultating on the thorax is:
Side to side comparison
300
The main reason auscultation precedes percussion & palpation of the abdomen is to:
Prevent distortion of bowel sounds that might occur after percussion & palpation
300
During exam nurse notices left breast is larger than right. What should she do?
Finding is not unusual, but nurse should verify that this change is not new
300
Pt has black tarry stool. Possible cause would be:
Upper GI bleed
300
After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be: 1.objective. 2.reflective. 3.subjective. 4.introspective.
objective
400
During auscultation of breath sounds, what instruction do you give the patients?
Take a deep breath in/out though the mouth each time I put the stethoscope in a new location.
400
1. A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing:
Stress incontinence
400
During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement?
Open-ended question The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic
400
According to the biomedical model, a narrow definition of health is: A. an optimal functioning of mind, body, and spirit within the environment. B. the absence of disease. C. the response of the whole person to actual or potential problems. D. prevention of disease
the absence of disease.
400
75 yr old man, during the mental status portion of the exam the nurse can expect:
He may take a little longer to respond, but his general knowledge & abilities should not have declined
500
To assess the dorsalis pedis artery the nurse would palpate:
Lateral to the extensor tendon of the great toe
500
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be:
You need to get up slowly due to orthostatic hypotension
500
An example of subjective data is: A. decreased range of motion. B. crepitation in the left knee joint. C. left knee has been swollen and hot for the past 3 days. D. arthritis
Left knee has been swollen and hot for the past 3 days.
500
List the steps of the Nursing Process in order
assessment, nursing diagnosis, planning, implementation, and evaluation
500
Nurse suspects injured spleen. What is true regarding assessmt of spleen in this situation?
An enlarged spleen should not be palpated because it can rupture easily