Vital Signs
What is considered a normal temperature range for the adult client?
What is a temperature range: 35.8◦ C- 37.3◦ C (96.4◦F - 99.1◦F)
A dark-skinned client appears ashen grey and dull. The nurse would identify this as:
What is pallor?
A nurse assesses a client's visual acuity using a Snellen chart. What is the purpose of this assessment?
What is visual acuity?
The heart sound S1 and S2 are often described as a "lub-dub" and corresponds to what in the heart?
What is closure of AV valves (S1) and SL valves (S2)?
Describe to a new graduate nurse how to appropriately palpate a radial pulse.
What is using pads of first 3 fingers to palpate number of beats for 30 seconds and multiplying by 2 (if regular) or 60 seconds if irregular?
Start your count with “zero” for the first pulse felt. The second pulse felt is “one,” and so on.
Localized, non-blanchable color change to deep red, maroon, purple in intact or nonintact skin, Dark skin appears darker but does not blanch. Commonly on skin over coccyx, sacrum, buttocks, heels.
What is deep tissue injury (DTPI)?
The nurse is assessing an older adult client’s ear and see the following findings: coarse wiry hairs in the ear canal, with white opaque tympanic membrane, and thick. The nurse would identify these findings as:
What is expected findings in the aging adult client’s ear?
A nurse notes a client with JVD, 2 + pitting edema, with a weak pulse and cool, moist skin. These findings indicate that which condition?
What is right-sided heart failure?
Upon entering the room, the nurse notices a client breathing 40 bpm? The nurse would interrupt this finding as.
What is tachypnea?
The ABCDEF is used to assess moles for potential malignancy. What does the “E” stand for?
What is elevation or evolution?
A client arrives to the clinic stating has been experiencing the following manifestations: goiter, eyelid retraction, and exophthalmos, feeling nervous and fatigued, weight loss, and heat intolerance. The nurse would identify these as:
What is hyperthyroidism?
Describe how to assess APETM and include landmarks.
What is Aortic (2nd ICS, Right sternal border), Pulmonic (2nd ICS, Left Sternal border), Erb's point (3rd ICS, left sternal border), Tricuspid (4th ICS, left sternal border), mitral (5th ICS, MCL)?
During a routine check, the nurse notes that a client’s pulse oximetry reading is 88%. What is the priority nursing action?
A) Administer oxygen as prescribed
B) Document the finding
C) Recheck the pulse oximetry after 10 minutes
D) Assess the client’s level of consciousness
What is administer oxygen as prescribed?
A nurse is performing a skin, hair, and nails assessment on a 65-year-old patient. Which of the following findings would be considered a normal age-related change?
A. thickened, yellow toenails
B. Increased hair growth on the arms and legs
C. Smooth, evenly pigmented skin with no lesions
D. Decreased skin elasticity and wrinkling
What is decreased skin elasticity and wrinkling?
A nurse is performing a HEENT assessment on a 45-year-old client. During the assessment, the client reports experiencing a sensation of fullness in the ears and difficulty hearing. What is the most appropriate follow-up question the nurse should ask to further assess the client's condition?
A) "Have you had any recent colds or sinus infections?"
B) "Do you have a history of ear infections?"
C) "Have you been exposed to loud noises recently?"
D) "Are you experiencing any dizziness or vertigo?"
What is "have you had any recent colds or sinus infections?"
While performing a cardiac assessment, the nurse notes the presence of a third heart sound (S3) in a client. Which of the following conditions might this finding suggest?
A) Myocardial infarction
B) Heart failure
C) Aortic stenosis
D) Pericarditis
What is heart failure?
The nurse is teaching a client about the importance of monitoring blood pressure. Which statement by the client indicates a need for further teaching?
A) “I should avoid caffeine before my blood pressure is taken.”
B) “I can take my blood pressure immediately after exercise.”
C) “It’s important to rest for a few minutes before the measurement.”
D) “I will use the same arm for each measurement.”
What is “I can take my blood pressure immediately after exercise.”
The nurse is assessing several skin lesions. Which would the nurse recognize as the priority for referral for skin biopsy?
A. Asymmetrical; tan with a defined border; 3mm
B. Asymmetrical; brown with a black, irregular border; 6.5 mm
C. Symmetrical; dark brown with a regular border; 7 mm
D. Symmetrical; brown with an irregular border; 5 mm
What is asymmetrical; brown with a black, irregular border; 6.5 mm?
A nurse is performing the whisper test to assess a client’s hearing. Which of the following actions should the nurse take to ensure accurate results?
A) Stand directly in front of the client and whisper softly.
B) Cover the client’s ear opposite to the one being tested.
C) Use a loud voice to ensure the client hears the whisper.
D) Whisper a series of numbers to assess auditory comprehension.
What is cover the client’s ear opposite to the one being tested?
A client with a history of coronary artery disease is being assessed in the clinic. Which of the following findings would most likely indicate the need for immediate intervention?
A) The client reports occasional chest discomfort with exertion.
B) The client’s heart rate is 88 beats per minute.
C) The client exhibits swelling in the ankles.
D) The client states they have not been taking their prescribed aspirin.
What is the client states they have not been taking their prescribed aspirin?