While assessing a newborn, the nurse wears sterile gloves and inserts the little finger into the newborn's mouth. What would the nurse assess in the newborn by performing this intervention? Show
A) Scarf sign B) Ortolani sign C) Sucking reflex D) Babinski reflex C) Sucking reflex The nurse is planning to assess a hospitalized patient with active tuberculosis. Which assessment should the nurse complete first? A) Whether the patient has any breathing difficulty B) Whether the patient has had a recent chest x-ray C) Whether the patient's room has a marker for isolation D) Whether the patient received the prescribed doses of antibiotics C) Whether the patient's room has a marker for isolation After assessing a patient, the nurse documents that the patient has a tender ear. Which intervention helped the nurse reach this conclusion? A) Performing the whisper voice test B) Performing bimanual examination C) Moving the auricle and pushing tragus D) Inspecting the internal ear using an otoscope C) Moving the auricle and pushing tragus While performing an oral examination, the nurse instructs the patient to say "ahh." What is the reason for giving this instruction? A) To inspect the uvula B) To inspect the hard palate C) To inspect the buccal mucosa D) To inspect the teeth and gums A) To inspect the uvula Which actions would the nurse perform in order to detect ear disorders in a newborn? A) Complete an otoscopic examination in the newborn B) Determine the presence of the scarf sign in the newborn C) Assess for the presence of the red reflex in the newborn D) Detect a palpebral slant in the newborn by using a penlight E) Note the presence of the startle reflex in the newborn due to a loud noise A) Complete an otoscopic examination in the newborn E) Note the presence of the startle reflex in the newborn due to a loud noise While assessing an infant, the nurse pulls the infant's arm across its chest and finds that the infant's elbow does not cross the midline. What should the nurse infer from this finding? A) Absence of the scarf sign B) Presence of the Moro reflex C) Absence of the Ortolani sign D) Presence of the Babinski reflex A) Absence of the scarf sign While preparing the patient for an ophthalmic examination, the nurse places an index card on the patient's left eye. What is the reason behind this action? A) To test the red reflex B) To inspect the fundus C) To conduct the cover test D) To test for the blink reflex C) To conduct the cover test Which vital signs does the nurse generally note while assessing a healthy neonate? A) Pain B) Pulse C) Respiration D) Temperature E) Blood pressure B) Pulse C) Respiration D) Temperature Which methods would trigger the Moro reflex in an infant? A) Shaking the sides of the infant's crib B) Startling the infant by making a loud noise C) Tapping the infant's biceps with a reflex hammer D) Looking at the infant's eyes with an ophthalmoscope E) Dropping the infant's head suddenly for a short distance A) Shaking the sides of the infant's crib B) Startling the infant by making a loud noise E) Dropping the infant's head suddenly for a short distance While examining a patient, the nurse finds that the patient has an impaired gag reflex. Which nerves does the nurse expect to be responsible for this condition? A) Cranial nerve III B) Cranial nerve VII C) Cranial nerve IX D) Cranial nerve X E) Cranial nerve XII C) Cranial nerve IX D) Cranial nerve X The nurse plans to administer intravenous analgesics to a patient who had cardiac surgery the previous day. Currently, the patient is on intravenous fluids, which is administered through the left brachial vein. What measure should the nurse take to provide effective care to the patient? A) The nurse should assess the patient's pain using the facial grimace scale. B) The nurse should ensure that the patient's oxygen saturation is more than 92%. C) The nurse should regularly assess the blood pressure in the left arm of the patient. D) The nurse should monitor the patient's pain 60 minutes after administering the analgesic. B) The nurse should ensure that the patient's oxygen saturation is more than 92%. While examining a patient, the nurse suspects that the patient may have injury to cranial nerve XII. Which finding enabled the nurse to reach this conclusion? A) The patient is unable to speak properly. B) The patient is unable to raise the soft palate. C) The patient is unable to stick out the tongue. D) The patient is unable to swallow solid foods. C) The patient is unable to stick out the tongue. Which intervention does the nurse perform while assessing the breasts in a patient? A) Percuss the costovertebral angle B) Palpate the epitrochlear nodes C) Stand closely and check for Romberg sign D) Inspect the supraclavicular and infraclavicular areas D) Inspect the supraclavicular and infraclavicular areas While examining the patient, the nurse finds that the patient's respiratory rate is 10 breaths/minute, urinary output is 50 mL/ hour, and body temperature is 98° F (36.6° C). Which intervention does the nurse expects to be beneficial for the patient? A) Providing excess oral fluids B) Teaching deep breathing exercises C) Reducing the room temperature D) Placing the patient in a prone position B) Teaching deep breathing exercises The nurse is examining a patient. Which findings documented by the nurse are considered normal? A) The gag reflex is present. B) S3 and S4 heart sounds are absent. C) The uvula is deviated to the left side during phonation. D) Apical pulse is present in the seventh intercostal space. E) Tympanic percussion note is present in the left upper quadrant of the abdomen. A) The gag reflex is present. B) S3 and S4 heart sounds are absent. E) Tympanic percussion note is present in the left upper quadrant of the abdomen. Which parameters should the nurse assess while examining a patient's abdomen? A) Apical pulse B) Bowel sounds C) Femoral pulse D) Cardiac murmurs E) Dorsalis pedis pulse B) Bowel sounds C) Femoral pulse The nurse finds a positive Babinski reflex in an adult during a physical assessment. What could be the reason for such an abnormality? A) Neurologic impairment B) Cardiovascular impairment C) Musculoskeletal impairment D) Gastrointestinal impairment A) Neurologic impairment While assessing an infant, the nurse lifts the infant by supporting the shoulders and lets the infant's head drop back. What is the rationale behind this assessment? A) To examine the neck of the infant B) To test the Babinski reflex in the infant C) To test for the Moro reflex in the infant D) To look at auricle alignment in the infant A) To examine the neck of the infant While examining the eyes, the nurse finds that the patient has 20/20 vision, symmetric corneal reflex, and white sclera. The patient's pupil size is 3 mm while resting and 2 mm while constricting. What does the nurse infer from these findings? A) The patient has ptosis. B) The patient has strabismus. C) The patient has nystagmus. D) The patient has normal vision. D) The patient has normal vision. During an assessment, the nurse suspects that the patient has a risk of peripheral vascular disease. What should the nurse palpate in order to determine the blood supply to the patient's lower extremities? A) The apical impulse B) The dorsalis pedis pulse C) The inguinal lymph nodes D) The cervical lymph nodes B) The dorsalis pedis pulse A patient who had an accident has severe bleeding and injuries. The health care provider prescribes a blood transfusion and intravenous fluids for the patient. Which interventions would the nurse complete while caring for this patient? A) Clean the patient's wounds by using 10% phenol. B) Note the skin condition around the intravenous site. C) Dress the patient's wounds while noting the skin integrity. D) Label the intravenous site with the date and time of insertion. E) Assess the skin turgor by pinching the skin under the clavicle. B) Note the skin condition around the intravenous site. D) Label the intravenous site with the date and time of insertion. E) Assess the skin turgor by pinching the skin under the clavicle. The nurse administers an oral analgesic to a patient. When should the nurse assess pain reduction after administration of the medication to determine the efficacy of the treatment? A) After 15 minutes B) After 30 minutes C) After 60 minutes D) After 120 minutes C) After 60 minutes The nurse supervises a student nurse who is performing the cardiovascular assessment of a patient. Which step taken by the student nurse needs correction? A) Checking the capillary refill for prompt return B) Comparing the apical pulse with the radial pulse C) Auscultating the apical pulse after removing the patient's gown D) Assessing the heart sounds by first using the bell of the stethoscope D) Assessing the heart sounds by first using the bell of the stethoscope The nurse is caring for a pregnant patient who has been administered epidural anesthesia during labor. Which intervention would the nurse follow to ensure the patient's safety? A) Monitor patient's vitals every 4 hours. B) Administer intravenous analgesics to the patient. C) Ensure that the patient has 92% oxygen saturation. D) Place the patient in the prone position after the procedure. C) Ensure that the patient has 92% oxygen saturation. What does the nurse assess with the help of an ophthalmoscope? A) Red reflex B) Blink reflex C) Pupillary reflex D) Corneal light reflex A) Red reflex While examining a patient with peripheral artery disease, the nurse was unable to palpate the dorsalis pedis pulse. Which intervention should the nurse complete immediately? A) Elevate the patient's bed to a 45° angle B) Perform Doppler imaging on the patient C) Obtain an order for an electrocardiogram D) Administer cardiac glycosides to the patient B) Perform Doppler imaging on the patient What is the most likely reason for assessing a young child's ear? A) Assessing for startle reflex B) Checking for a foreign body C) Assessing for extra skin tags D) Inspecting alignment of auricles B) Checking for a foreign body What does the nurse do to elicit the placing reflex in an infant? A) Let the infant's head and trunk drop back a short way B) Place the infant supine and note the movements of the neck C) Position the infant against the edge of the examination table D) Pull up the infant by wrapping hands around the infant's hands C) Position the infant against the edge of the examination table The nurse is planning to administer the Denver II with a group of preschool children in order to evaluate their developmental milestones. What should the nurse ask the children to do during the test? A) Throw a ball B) Build a tower C) Identify colors D) Repeat a sentence E) Stand on one foot A) Throw a ball B) Build a tower E) Stand on one foot The health care professionals in a hospital use built-in checklists in electronic health records (EHRs) for patient care. For what are these checklists used? A) To identify patients B) To identify medications C) To screen for depression D) To screen for suicidal tendency E) To identify health care-associated infections C) To screen for depression D) To screen for suicidal tendency E) To identify health care-associated infections During the assessment of the patient, the nurse asks the patient to push both the feet against the nurse's palm. What is the nurse assessing by doing this? A) The sensation of the lower limb B) The balance of the lower limbs C) The skin turgor in the lower limbs D) The strength of the lower limb muscles D) The strength of the lower limb muscles The nurse is auscultating the breath sounds of a patient who has undergone abdominal surgery. The patient is not able to tolerate a sitting position in bed. What measure should the nurse take to auscultate the posterior lobe of the lung of the patient? A) Ask another nurse to hold the patient in a sitting position. B) Ask another nurse to hold the patient in side-lying position. C) Ask another nurse to position the patient in prone position. D) Ask another nurse to raise the patient's upper back slightly from the bed. B) Ask another nurse to hold the patient in side-lying position. The nurse documents normocephalic as an assessment finding. What did the nurse assess in the patient? A) Cranium B) Abdomen C) Optic nerve D) Mental status A) Cranium While testing the extraocular muscles, the nurse notes that the patient has improper eye movements. Which cranial nerve damage does the nurse suspect in the patient? A) Cranial nerve III B) Cranial nerve IV C) Cranial nerve VI D) Cranial nerve VII E) Cranial nerve IX A) Cranial nerve III B) Cranial nerve IV C) Cranial nerve VI While performing a visual examination of a patient, the nurse tests the visual fields by using the confrontation technique. Which cranial nerve does the nurse test through this assessment? A) Cranial nerve II B) Cranial nerve III C) Cranial nerve IV D) Cranial nerve VI A) Cranial nerve II The nurse is preparing to examine a geriatric patient. Which interventions would the nurse plan to obtain data about the patient's neurologic functioning? A) The nurse would offer a glass of water to the patient. B) The nurse would check the changes in the pupil in response to light. C) The nurse would check the patient's fat distribution and hydration status. D) The nurse would check the patient's apical pulse against the radial pulse. E) The nurse would ask the patient to push his or her feet against the nurse's palm. A) The nurse would offer a glass of water to the patient. B) The nurse would check the changes in the pupil in response to light. E) The nurse would ask the patient to push his or her feet against the nurse's palm.
The nurse is caring for a patient who has undergone knee replacement surgery the previous day. After reviewing the patient's medical record, the nurse suspects that the patient has a risk of genitourinary disorder. Which finding is consistent with this condition? A) The patient's urine is amber colored. B) The patient's urine is clear without froth. C) The patient's urine output is 30 mL/hour. D) The patient voids 12 hours after the surgery. D) The patient voids 12 hours after the surgery. The nurse observes a student nurse who is examining the mouth, throat, nose, and eyes of a young child. Which intervention by the student nurse needs correction? A) Using a penlight to determine the cardinal positions of gaze B) Using an ophthalmoscope to verify the red reflex in the child C) Using a penlight to inspect for any foreign bodies in the nose D) Using a tongue blade initially to examine the mouth and the throat D) Using a tongue blade initially to examine the mouth and the throat Which part of the body should the nurse examine to assess cranial nerve VII? A) Eye B) Face C) Mouth D) Throat B) Face While assessing a patient, the nurse finds that the patient has ptosis. What does the nurse conclude from this finding? A) The patient has a risk of hearing impairment. B) The patient has a risk of genitourinary disorders. C) The patient has impaired cardiovascular functioning. D) The patient has impaired neuromuscular development. D) The patient has impaired neuromuscular development. The nurse is performing breast examination on a female patient. Which position of the patient does the nurse find most suitable during the assessment? A) Prone position B) Supine position C) Sitting position D) Lithotomy position B) Supine position The nurse instructs a student nurse to assess an infant's growth by using a growth chart. Which parameters would the student nurse measure? A) Weight B) Length C) Blood pressure D) Respiratory rate E) Head circumference A) Weight B) Length E) Head circumference The nurse is caring for a patient who has undergone abdominal surgery on the previous day. The nurse finds that the patient's oxygen saturation has dipped from 98% to 95% in 30 minutes. What measure should the nurse take to improve the gas exchange in the patient? A) Ask the patient cough 10 times every 15 minutes. B) Encourage the patient to walk around the corridor for 30 minutes. C) Administer supplemental oxygen through a low flow device to the patient. D) Ask the patient to take 10 breaths through an incentive spirometer every 15 minutes. D) Ask the patient to take 10 breaths through an incentive spirometer every 15 minutes. The nurse is performing a breast examination on a patient. Which instruction does the nurse give during the exam? A) "Shrug your shoulders." B) "Lift your arms over your head." C) "Bend forward a little and exhale." D) "Press your arms against your torso." E) "Put your hands on your hips and lean forward." B) "Lift your arms over your head." E) "Put your hands on your hips and lean forward." When informing the health care provider about the patient's condition, the nurse uses the Situation, Background, Assessment, and Recommendation (SBAR) framework. What would be the advantages of using the SBAR framework during verbal reporting? A) It keeps the message concise. B) It focuses on the patient's immediate problem. C) It reports the patient's past medical history in detail. D) It helps in making effective decisions regarding the patient's care. E) It helps in effective communication between the nurse and the patient. A) It keeps the message concise. B) It focuses on the patient's immediate problem. D) It helps in making effective decisions regarding the patient's care. Which reflexes would the nurse test by using a reflex hammer? A) Red reflex B) Moro reflex C) Achilles reflex D) Patellar reflex E) Plantar reflex C) Achilles reflex D) Patellar reflex E) Plantar reflex What should the nurse assess as a young child plays with toys in the examination room? A) Alignment of the legs B) Gross and fine motor skills C) Size and shape of the head D) Parent and child interaction B) Gross and fine motor skills While recording a patient's vital signs, the nurse finds that the patient has a systolic blood pressure of 80 mm Hg, a respiratory rate of 16 breaths per minute, and an oxygen saturation of 90%. What does the nurse infer from these findings? A) The patient has a high respiratory rate and hypoxemia. B) The patient has a low systolic blood pressure and hypoxemia. C) The patient has a high respiratory rate and low systolic blood pressure. D) The patient has a low respiratory rate and high systolic blood pressure. B) The patient has a low systolic blood pressure and hypoxemia. The nurse instructs a student nurse to assess the patency of the anus in a 1-day-old neonate. How should the student nurse determine this? A) Check for the Ortolani sign B) Palpate the dorsalis pedis pulse C) Palpate the inguinal lymph nodes D) Check for the passage of meconium D) Check for the passage of meconium While collecting data, the nurse uses the Snellen chart. What does the nurse examine in the patient? A) Vision acuity B) Stereognosis C) Facial symmetry D) Costovertebral angle A) Vision acuity Which intervention does the nurse follow while assessing cerebellar function in a patient? A) Ask the patient to move the heel down along the opposite shin. B) Ask the patient to bend the knee by holding the edge of the bed. C) Check the spinal position when the patient bends to touch the toes. D) Ask the patient to walk on the toes and heels alternately for a few steps. A) Ask the patient to move the heel down along the opposite shin. What does the nurse assess as a part of the musculoskeletal assessment of an adult patient's lower extremities? A) Red reflex B) Romberg test C) Brachial index D) Babinski reflex B) Romberg test Which assessment should the nurse perform last during an infant examination? A) Inspecting the tympanic membranes B) Assessing the infant for the startle reflex C) Examining the symmetry of the gluteal folds D) Inspecting the trunk for the incurvation reflex A) Inspecting the tympanic membranes The nurse is completing a detailed assessment of a patient. Which data obtained from the patient would the nurse document under the functional assessment? A) The patient is a high school graduate. B) The patient wakes up daily at 7:00 AM. C) The patient does not have any allergies. D) The patient skips breakfast most of the time. E) The patient had a motor vehicle accident 3 years ago. A) The patient is a high school graduate. B) The patient wakes up daily at 7:00 AM. D) The patient skips breakfast most of the time. The nursing instructor is evaluating the student nurse examining the genitals of a male neonate. Which intervention done by the student nurse needs correction? A) Inspecting the location of the urethral meatus B) Inspecting the strength of the infant's urine stream C) Inspecting the glans penis by retracting the foreskin D) Inspecting the testes by palpating the infant's scrotum C) Inspecting the glans penis by retracting the foreskin What would the nurse assess in a patient by using an otoscope? A) Presence of the red reflex B) Absence of the Ortolani sign C) Patency of both of the nostrils D) Condition of the auditory canal E) Intactness of the tympanic membrane D) Condition of the auditory canal E) Intactness of the tympanic membrane While assessing a patient, the nurse finds urine output to be 20 mL/hour. Which intervention should the nurse perform first? A) Administering a diuretic to the patient B) Performing a bladder scan on the patient C) Inserting a urinary catheter in the patient D) Administering intravenous fluids to the patient B) Performing a bladder scan on the patient A patient who has undergone nephrectomy is lethargic and reports severe pain in the abdomen. The health care provider instructed the nurse to administer an intravenous analgesic through the left brachial artery. Which intervention would the nurse follow while caring for this patient? A) Ambulate the patient every 20 minutes. B) Determine the right brachial blood pressure. C) Evaluate the intensity of pain every 6 hours. D) Monitor the rate of respirations every 4 hours. B) Determine the right brachial blood pressure. The nurse instructs a student nurse to monitor the pulse rate every 30 minutes, blood pressure every 1 hour, and temperature every 4 hours in a cancer patient. While recording the pulse rate, the student nurse gets distracted by the sound of a bell ring by a 2-year-old child in the adjacent room. What should the student nurse do in this situation? A) Ask the child to stop ringing the bells B) Inform the nurse about the child's action C) Continue recording the patient's pulse rate D) Determine the patient's pulse rate after 2 hours C) Continue recording the patient's pulse rate While assessing pain perception in a patient, the nurse finds that the patient has a distorted facial expression toward a pain stimulus. Which cranial nerve damage does the nurse screen for in the patient? A) Cranial nerve IV B) Cranial nerve VI C) Cranial nerve VII D) Cranial nerve IX C) Cranial nerve VII The nurses use bar-code scanners for medication administration. What are the objectives of using bar-code scanners? A) To identify patients B) To alert prescribers C) To identify medications D) To identify drug allergies E) To determine correct dosages A) To identify patients C) To identify medications What should the nurse do to assess cranial nerve II in a patient? A) Test the visual fields of the patient. B) Test the patient's corneal light reflex. C) Inspect the conjunctivae and sclerae. D) Inspect the external structures of the eye. A) Test the visual fields of the patient. The nurse asks a patient to bend the head forward and back, turn the head to either side, and to shrug the shoulders. What does the nurse assess from these tests? A) The patient's sense of balance B) The symmetry of the face and neck C) The functioning of cranial nerve XI D) The cerebellar function of the upper extremities C) The functioning of cranial nerve XI The nurse instructs the student nurse to assess the symmetry of the facial features and positioning of the face in a newborn. When should the student nurse conduct this examination in the newborn? A) When the newborn is eating B) When the newborn is crying C) When the newborn is cooing D) When the newborn is playing E) When the newborn is sleeping B) When the newborn is crying E) When the newborn is sleeping The nurse teaches a student nurse about breast examination. Which statement, if made by the student nurse, indicates effective learning? A) "Breast examination is done on male and female patients." B) "The patient remains in a standing position during breast examination." C) "Breast examination should be performed with a genital examination." D) "Breast examination should be performed with an anterior thorax examination." A) "Breast examination is done on male and female patients." The charge nurse informs the other nurses that the hospital has opted for basic electronic health record (EHR) adoption. What should the nurses understand from this? A) The EHR will be used for billing functions. B) The EHR will be used in all hospital functions. C) The EHR will be used in at least one clinical unit. D) The EHR will be used for scheduling patient visits. C) The EHR will be used in at least one clinical unit. The nurse is collecting data during a general assessment. Which information obtained from the patient would the nurse document under coping and stress management? A) The patient has no close friends. B) The patient does not have a job. C) The patient skips breakfast most days. D) The patient had a motor vehicle accident 3 years ago. E) The patient does not have any safety hazards in the home. B) The patient does not have a job. E) The patient does not have any safety hazards in the home. What assessments should the nurse include during an abdominal examination in a neonate? A) Inspecting the umbilical area B) Assessing the umbilical stump C) Counting the vessels in the cord D) Palpating deeply for muscle tone E) Auscultating the abdomen for bowel sounds A) Inspecting the umbilical area B) Assessing the umbilical stump C) Counting the vessels in the cord E) Auscultating the abdomen for bowel sounds The nurse is verbally reporting a postoperative patient's condition to the health care provider. The patient underwent abdominal surgery a day ago. The nurse states that the patient's blood pressure has decreased to 90/50 mm Hg and that an internal hemorrhage could be the reason. The patient is receiving intravenous fluids but may require a blood transfusion and emergency surgical exploration. Which statement by the nurse reflects the "A" element of the Situation, Background, Assessment, and Recommendation (SBAR) framework? A) The patient is postoperative. B) The patient's blood pressure is low and may be caused by internal hemorrhage. C) The patient may need a blood transfusion and surgical exploration. D) The patient underwent abdominal surgery a day ago. B) The patient's blood pressure is low and may be caused by internal hemorrhage. Which tests does the nurse perform while assessing the cerebellar function of a patient? A) Occult blood test B) Confrontation test C) Finger-to-nose test D) Whispered voice test E) Rapid-alternating-movements test C) Finger-to-nose test E) Rapid-alternating-movements test The nurse is assessing the level of consciousness of the patient. Which findings would indicate that the patient has impaired consciousness? A) The patient has a gloomy facial expression. B) The patient has a poor sense of personal hygiene. C) The patient does not have clear and well-articulated speech. D) The patient is not able to pay attention to the nurse's questions. E) The patient gives irrelevant responses to the questions asked by the nurse. D) The patient is not able to pay attention to the nurse's questions. E) The patient gives irrelevant responses to the questions asked by the nurse. The student nurse is assessing the neck of a patient under the supervision of a nurse educator. Which intervention by the student nurse needs correction? A) Palpation of the trachea in the midline B) Palpation of the cervical lymph nodes C) Assessment for functioning of cranial nerve XI D) Palpation of the carotid pulse on both sides at a time D) Palpation of the carotid pulse on both sides at a time A health care provider is working on patient data using an electronic health record (EHR). On entering a medication, the health care provider receives a drug allergy alert. Which statement best describes the health care provider's action? A) The health care provider is using CPOE. B) The health care provider is using SOAP. C) The health care provider is using SBAR. D) The health care provider is using a checklist. A) The health care provider is using CPOE. Which intervention by the nurse ensures the proper assessment of cardiac murmurs in a patient? A) Asking the patient to hyperextend the neck B) Asking the patient to rest in the prone position C) Asking the patient to shrug the shoulders vigorously D) Asking the patient to lean forward and exhale briefly D) Asking the patient to lean forward and exhale briefly What does the nurse assess while examining the posterior and lateral side of the chest? A) Shoulder shrug B) Tactile fremitus C) Epitrochlear nodes D) Costovertebral angle E) Length of the spinous process B) Tactile fremitus D) Costovertebral angle E) Length of the spinous process Which intervention does the nurse follow while examining the external genitalia of a male patient? A) Check for Romberg sign B) Check for inguinal hernia C) Palpate epitrochlear nodes D) Percuss costovertebral angle B) Check for inguinal hernia What question should the nurse ask during the pain assessment of a hospitalized cancer patient? A) "When did you last take pain medication?" B) "Which pain medications are you taking?" C) "Have you been given any epidural analgesia?" D) "Do you currently have any pain or discomfort?"
D) "Do you currently have any pain or discomfort?" What assessments should the nurse include while examining the chest of an infant? A) Palpating for skin turgor and muscle tone B) Observing the chest for signs of retraction C) Auscultating for bowel sounds in the abdomen D) Noting movement of the chest with respirations E) Palpating for the apical impulse and note its location
B) Observing the chest for signs of retraction C) Auscultating for bowel sounds in the abdomen E) Palpating for the apical impulse and note its location The nurse is supervising a student nurse who is assessing a patient in the cardiac unit. Which step taken by the student nurse needs correction? A) Introducing him- or herself after entering the patient's room B) Documenting the patient's vital signs after talking to the patient C) Repeating the questions asked by the nurse in the previous shift D) Maintaining direct eye contact with the patient during the assessment C) Repeating the questions asked by the nurse in the previous shift Which intervention should the nurse incorporate to open the eyes of a neonate for an examination? A) Place the neonate in a supine position on the examination table B) Ask the parent to hold the neonate while the head is tilted sideways C) Support the head and shoulders and gently lower the neonate backward D) Lift the neonate under the axillae, hold, and face the neonate at eye level C) Support the head and shoulders and gently lower the neonate backward The nurse is teaching a group of nursing students about the Situation, Background, Assessment, and Recommendation (SBAR) framework. Which statements should the nurse include in the teaching? A) "SBAR helps in decision making." B) "SBAR is a standardized framework." C) "SBAR focuses on chronic problems." D) "SBAR helps to reduce medical errors." E) "SBAR is a format for written communication." A) "SBAR helps in decision making." B) "SBAR is a standardized framework." D) "SBAR helps to reduce medical errors." While caring for a geriatric patient, the nurse suspects that the patient has a neurologic disorder. Which behaviors of the patient are consistent with a neurological disorder? A) The patient is difficult to arouse. B) The patient has altered level of consciousness. C) The patient avoids sharing feelings with the nurse. D) The patient responds slowly after being asked a question. E) The patient refuses to take the nurse's help while ambulating. A) The patient is difficult to arouse. B) The patient has altered level of consciousness. While reviewing the medical record of a patient with a renal disorder, the nurse finds that the patient has been administered an analgesic for relieving lower limb pain. Which question asked by the nurse may cause frustration in the patient? A) "How was your lower limb pain last night?" B) "Do you currently have pain in the lower limbs?" C) "How are you feeling after taking the painkiller?" D) "Did you get any relief after taking the painkiller?" B) "Do you currently have pain in the lower limbs?" Which assessments does the nurse complete while examining the neck of the patient? A) Palpate the thyroid gland. B) Palpate the epitrochlear nodes. C) Palpate the cervical lymph nodes. D) Check the carotid pulse, one at a time. E) Check the range of motion of the shoulder. A) Palpate the thyroid gland. C) Palpate the cervical lymph nodes. D) Check the carotid pulse, one at a time. What would the nurse assess in a patient's eyes by using an ophthalmoscope? A) Red reflex B) Blink reflex C) Pupillary light reflex D) Corneal light reflex ... Which instructions does the nurse give to the patient while assessing the spinal range of motion? A) "Hyperextend your neck." B) "Bend laterally downward." C) "Walk a few steps backward." D) "Perform five sit-ups in a row." E) "Walk a few steps on your heels." A) "Hyperextend your neck." B) "Bend laterally downward." What intervention does the nurse perform to test the stereognosis of a patient? A) Ask the patient to perform the rapid alternating movements test. B) Ask the patient to run each heel down the shin of the opposite leg. C) Ask the patient to extend the arms fully and touch the nose with a finger. D) Ask the patient to identify an object placed in the hand without visual clues. D) Ask the patient to identify an object placed in the hand without visual clues. Which involuntary responses does the nurse test in a newborn by using the reflex hammer? A) Red reflex B) Moro reflex C) Biceps reflex D) Triceps reflex E) Babinski reflex C) Biceps reflex D) Triceps reflex The nurse plans to assess the deep tendon reflexes of a patient. Which reflexes does the nurse check? A) Red reflex B) Biceps reflex C) Achilles reflex D) Patellar reflex E) Babinski reflex B) Biceps reflex C) Achilles reflex D) Patellar reflex What is Doppler imaging used for? A) It helps to determine muscle strength. B) It helps to determine the pupillary reflex. C) It helps to determine bladder functioning. D) It helps to assess pulses in the lower extremities. D) It helps to assess pulses in the lower extremities. What can the nurse assess using an otoscope? A) Ear canal B) Red reflex C) Babinski reflex D) Extraocular muscles E) Tympanic membrane A) Ear canal E) Tympanic membrane The student nurse is examining the external genitalia in a female patient under the supervision of the nurse. Which action of the student nurse needs correction? A) Draping the patient appropriately before starting the procedure B) Positioning the patient in the lithotomy position on the examination table C) Sitting on a stool near the foot of the table to perform speculum examination D) Sitting on a stool near the foot of the table to perform bimanual examination D) Sitting on a stool near the foot of the table to perform bimanual examination Which reflex is the nurse assessing in a newborn when the nurse places a finger in the infant's palm? A) Grasp reflex B) Biceps reflex C) Rooting reflex D) Babinski reflex A) Grasp reflex Which assessment includes size, shape, and strength parameters? A) Breast examination B) Abdominal examination C) Cardiovascular examination D) Musculoskeletal examination D) Musculoskeletal examination The nurse is assessing the skin of the patient. How would the nurse assess the skin turgor of the patient? A) By pinching the skin of the forearm B) By palpating the skin on the forearm C) By palpating the skin on the forehead D) By pinching the skin over the forehead A) By pinching the skin of the forearm The nurse reports to the health care provider that a 1-year-old child admitted to the hospital 3 days ago with high fever has had a seizure. The child is safe and has no physical injuries. The fever is high, and the child may need injectable antipyretics. The nurse requests that the health care provider see and assess the child and plan further interventions. Which of the nurse's statements reflects the "R" element of the Situation, Background, Assessment, and Recommendation (SBAR) framework? A) The child is safe and has no physical injury. B) A 1-year-old child admitted with fever has had a seizure. C) The child has a high fever and may need injectable antipyretics. D) The health care provider should see the child and plan further treatment. D) The health care provider should see the child and plan further treatment. The nurse is assessing the peripheral circulation of a patient. The patient has lower limb edema, and the nurse is not able to palpate the posterior tibial and dorsalis pedis pulsations. What action should the nurse take? A) Assess the pulsations through Doppler imaging. B) Assess the pulsation using magnetic resonance imaging. C) Assess the pulsations after elevating the patient's limbs. D) Assess the pulsations after the swelling has subsided. A) Assess the pulsations through Doppler imaging. Which assessment should the nurse include in order to assess an infant's upper extremities? A) Grasp reflex B) Rooting reflex C) Babinski reflex D) Stepping reflex A) Grasp reflex While assessing a male patient, the nurse asks the patient to close his eyes and places a familiar object in his hand. The nurse then asks the patient to identify the object. What does the nurse check through this assessment? A) Red reflex B) Stereognosis C) Babinski reflex D) Cerebellar function B) Stereognosis
What is the nurse assessing in a newborn by using the Apgar scoring system five minutes after birth? A) Hearing ability in the newborn B) Visual disorders in the newborn C) Neuromuscular function in the newborn D) Response of the newborn to extrauterine life D) Response of the newborn to extrauterine life What does the nurse assess when lightly palpating an infant's abdomen? A) Kidneys B) Spleen tip C) Muscle tone D) Urinary bladder E) Presence of a mass B) Spleen tip C) Muscle tone D) Urinary bladder Which patient data are important to be conveyed to the health care provider when using the Situation, Background, Assessment, and Recommendation (SBAR) framework? A) Vital parameters B) Signs and symptoms C) Past medical history D) Current medications E) Previous hospitalizations A) Vital parameters B) Signs and symptoms D) Current medications The nurse is completing an electronic health record (EHR) for a new patient. Which patient data should the nurse include? A) Scheduled visits B) Clinical findings C) Medical history D) Expenses incurred E) Laboratory results B) Clinical findings C) Medical history E) Laboratory results While doing a well-child examination of a preschooler, the student nurse initially involves the child in play and asks the child to jump and hop. Then the student nurse uses an otoscope to detect the red reflex in the child. The student nurse then asks the child to remove the underpants and performs a genital examination. Then the student nurse gives the child a pinwheel as a present. Which action of the student nurse needs correction? A) Using an otoscope to assess the red reflex in the child B) Presenting the pinwheel to the child after the examination C) Initially involving the child in play and then in jumping and hopping D) Having the child remove his or her underpants to look at the genitals A) Using an otoscope to assess the red reflex in the child Health care professionals use the SBAR framework for reporting patient information. What does "S" stand for in SBAR? A) Safety B) Subjective C) Situation D) Symptoms C) Situation The nurse is performing an otoscopic examination in a preschooler. The child refuses to sit still on the chair and does not cooperate with the nurse during the examination. Which intervention should the nurse use to gain the child's cooperation? A) Restrain the child to do the examination B) Instruct the child in a firm voice to sit still C) Ask the parents to hold the child very firmly D) Encourage the child to handle the otoscope D) Encourage the child to handle the otoscope The nurse uses the Situation, Background, Assessment, and Recommendation (SBAR) framework when reporting to a primary health care provider about a patient's condition. The nurse reports that the patient needs a central venous access because the peripheral veins are collapsed. Which element of the SBAR does the nurse's statement reflect? A) S B) B C) A D) R D) R How does the nurse record the size and placement of skin lesions? A) Take a photograph of the lesion. B) Write down the disease that caused the lesion. C) Use comparisons to everyday items such as coins. D) Draw a diagram or picture of the lesion and landmarks. E) Write a detailed description of the lesion into the record. A) Take a photograph of the lesion. D) Draw a diagram or picture of the lesion and landmarks. E) Write a detailed description of the lesion into the record. Which assessments should the nurse perform during the neurologic examination of a patient? A) Checking for inguinal hernia B) Checking for pain perception C) Checking for deep tendon reflexes D) Checking for position sense of finger E) Checking for jugular venous pressure B) Checking for pain perception C) Checking for deep tendon reflexes D) Checking for position sense of finger The nurse is using a penlight to assess a patient with an ophthalmic disorder. Which parameters will the nurse test by using the penlight? A) Red reflex B) Blink reflex C) Palpebral slant D) Pupillary light reflex E) Corneal light reflex B) Blink reflex D) Pupillary light reflex E) Corneal light reflex What does the nurse assess while examining the head and face of a patient? A) Tactile fremitus B) Temporal pulsations C) Extraocular muscles D) Temporomandibular joint E) Maxillary and frontal sinus B) Temporal pulsations D) Temporomandibular joint E) Maxillary and frontal sinus While examining a patient, the nurse checks the patient's weight, determines body mass index, and hydration status. What is the rationale behind these interventions? A) To identify neurologic disorders in the patient B) To establish the nutritional status of the patient C) To identify gastrointestinal disorders in the patient D) To determine the endocrine functioning in the patient B) To establish the nutritional status of the patient While assessing a patient with peripheral vascular disorder, the nurse finds that the patient has lower limb edema and lesions on the legs. What would the nurse do in order to provide effective treatment for the patient? A) Check hemoglobin levels B) Recommend a bladder scan C) Palpate the posterior tibial pulse D) Determine blood glucose levels C) Palpate the posterior tibial pulse What should the nurse determine while assessing the neurologic status of a patient? A) Ability to swallow food and water B) Consciousness level of the patient C) Muscle strength of left and right upper limbs D) Use of accessory muscles during respiration E) Change in pupil size in response to light in centimeters A) Ability to swallow food and water B) Consciousness level of the patient C) Muscle strength of left and right upper limbs Which parameters should the nurse assess while examining a child's upper extremities? A) Radial pulse B) Femoral pulse C) Stepping reflex D) Dorsalis pedis pulse E) Biceps and triceps reflexes A) Radial pulse E) Biceps and triceps reflexes What would the nurse assess while examining a patient's head, face, and neck? A) Trachea B) Thyroid gland C) Shoulder symmetry D) Cervical lymph nodes E) Trunk incurvation reflex A) Trachea B) Thyroid gland D) Cervical lymph nodes A new nurse is caring for a bedridden patient. Which measure, if taken by the nurse, would be inappropriate? A) Ensuring that there are no areas of skin breakdown B) Checking if the patient can tolerate the change in position C) Confirming that the head of the patient's bed is not elevated D) Applying thromboembolic disease hose for at least 22 hours a day C) Confirming that the head of the patient's bed is not elevated The nurse places an infant on a soft, padded surface while gently lifting the infant by supporting the head. After a while, the nurse allows the infant's head and trunk drop back a short way. What reflex is the nurse observing by doing this? A) Red reflex B) Moro reflex C) Babinski reflex D) Doll's eye reflex B) Moro reflex After assessing a 15-month-old child, the nurse concludes the child has impaired neuromuscular development. Which finding supports the nurse's conclusion? A) Presence of the grasp reflex B) Presence of the Babinski reflex C) Nonexistence of the Ortolani sign D) Nonappearance of the red reflex A) Presence of the grasp reflex The nurse assesses that a 3-year-old child has a Babinski reflex. What risk does this child have? A) Genital disorders B) Ophthalmic disorders C) Cardiovascular disorders D) Neuromuscular disorders D) Neuromuscular disorders The nurse is performing a well-child examination in a preschooler. What should the nurse include to provide effective care for the child? A) Not converse with the child throughout the examination B) Thoroughly explain all the steps of the examination to the child C) Ask the child to blow on a pinwheel to listen to the lung sounds D) Ask the child to stand on one foot and build a tower with blocks E) Not ask the child to remove the underpants to examine the genitalia B) Thoroughly explain all the steps of the examination to the child C) Ask the child to blow on a pinwheel to listen to the lung sounds D) Ask the child to stand on one foot and build a tower with blocks A patient with renal failure who was admitted to the hospital a week ago suddenly develops breathlessness. The nurse uses the Situation, Background, Assessment, and Recommendation (SBAR) framework to report it to the health care provider. Which statements should the nurse include in the framework? A) The blood work shows increased urea and creatinine levels. B) The patient looks toxic and may benefit from peritoneal dialysis. C) On admission, the patient had a blood pressure of 120/80 mm Hg. D) The patient had undergone laparoscopic cholecystectomy 10 years ago. E) The respiratory rate is 28 breaths per minute and the oxygen saturation is 93%. A) The blood work shows increased urea and creatinine levels. B) The patient looks toxic and may benefit from peritoneal dialysis. E) The respiratory rate is 28 breaths per minute and the oxygen saturation is 93%. While assessing a patient, the nurse finds that the patient's respiratory rate is 26 breaths/minute, urinary output is 40 mL/hour, body temperature is 98° F (36.6° C), and heart rate is 120 beats/minute. What does the nurse interpret from these findings? A) The patent has bradypnea. B) The patient has tachycardia. C) The patient has hyperthermia. D) The patient has urinary retention. B) The patient has tachycardia. While completing a neuromuscular assessment in a newborn, the nurse turns the newborn's head from one side to the other. Which reflex can the nurse test in the newborn with this intervention? A) Grasp reflex B) Rooting reflex C) Babinski reflex D) Doll's eye reflex D) Doll's eye reflex After reviewing the medical history of a 3-year-old child, the nurse finds the child has appropriate growth and development. Which findings enabled the nurse to reach this conclusion? A) The child exhibits a positive red reflex. B) The child demonstrates a positive Ortolani sign. C) The child passed meconium 24 hours after birth. D) The child had a Babinski reflex until 2 years of age. E) The child had plantar grasp reflex until 13 months of age. A) The child exhibits a positive red reflex. C) The child passed meconium 24 hours after birth. D) The child had a Babinski reflex until 2 years of age. While examining a newborn, the nurse inspects the trunk incurvation reflex. What body part is the nurse assessing by doing this? A) Lower limbs B) Upper limbs C) Genital organs D) Spinal column D) Spinal column The nurse is assessing a patient who had undergone renal surgery 4 hours ago. Which assessment findings documented by the nurse are normal? A) Urine of a dark amber color B) Oxygen saturation of 90% C) Urine output of 20 mL/hour D) Body temperature of 98.6° F (37° C) E) Respiratory rate of 10 breaths per minute A) Urine of a dark amber color D) Body temperature of 98.6° F (37° C) In which situations should the nurse use the Situation, Background, Assessment, and Recommendation (SBAR) framework for communication? A) When recording vital signs in the patient's chart B) When organizing assessment findings on the admission form C) When informing a nurse in another unit about the patient's transfer D) When calling the health care provider to report the patient's condition E) When giving nursing shift reports to other nurses working the next shift C) When informing a nurse in another unit about the patient's transfer D) When calling the health care provider to report the patient's condition E) When giving nursing shift reports to other nurses working the next shift The nurse is discussing the advantages of electronic health records (EHRs) over paper records with a group of nursing students. Which statement by a student nurse indicates effective learning? A) "EHR adoption can be limited by resource constraints." B) "EHRs are a cost-effective method of documentation." C) "EHRs are helpful in increasing the standard of care provided." D) "EHRs are accessible only to the treating health care provider" E) "EHRs sometimes can be illegible because of poor handwriting." A) "EHR adoption can be limited by resource constraints." B) "EHRs are a cost-effective method of documentation." C) "EHRs are helpful in increasing the standard of care provided." The nurse is caring for a patient with abdominal discomfort. Which intervention should the nurse implement? A) Determine whether the patient is able to tolerate ice chips B) Listen to the bowel sounds in the patient's left lower quadrant C) Encourage the patient to take deep breaths every 10 minutes D) Place the patient in the supine position and elevate the legs at a 45° angle A) Determine whether the patient is able to tolerate ice chips Before beginning the assessment, the nurse offers water to the patient. What would the nurse assess in the patient while doing this? A) The patient is able to hear normally. B) The patient is able to speak normally. C) The patient is able to follow directions. D) The patient is able to recall memories. E) The patient is able to swallow normally. A) The patient is able to hear normally. C) The patient is able to follow directions. E) The patient is able to swallow normally. The nurse is caring for a patient who has hypovolemia caused by severe bleeding. The health care provider has prescribed a blood transfusion and intravenous (IV) lactated Ringer solution. Which action would the nurse follow to provide effective care to the patient? A) The nurse would cross-check the label on the IV solution with the written prescription. B) The nurse would flush the IV tubing with dextrose before transfusing the blood. C) The nurse would raise the patient's bed at an angle of 45° while administering blood. D) The nurse would administer blood and lactated Ringer solution simultaneously. A) The nurse would cross-check the label on the IV solution with the written prescription. The nurse has assessed the patients on the unit. Which patient should be attended to first? A) A patient who reports amber colored urine after a ureteroscopy procedure B) A patient with a heart rate of 84 beats per minute and oxygen saturation of 99% C) A patient with blood pressure of 180/110 mm Hg and urine output of 30 mL/hour D) A patient with a respiratory rate of 16 breaths per minute and temperature of 98.6°F (37° C) C) A patient with blood pressure of 180/110 mm Hg and urine output of 30 mL/hour Which test helps the nurse determine a neonate's immediate response to extrauterine life? A) Red reflex B) Cover test C) Apgar score D) Biceps reflex C) Apgar score The nurse is caring for a patient who has undergone abdominal surgery the previous day. The patient has a stable oxygen saturation of 96%. The health care provider has prescribed an incentive spirometer for the patient. What instruction should the nurse give to the patient regarding using the incentive spirometer? A) "Take 10 deep inspirations every hour using this device." B) "Take 3 deep inspirations every hour using this device." C) "Take 10 deep inspirations every 15 minutes using this device." D) "Take 3 deep inspirations every 30 minutes using this device." A) "Take 10 deep inspirations every hour using this device." The nurse supervises a student nurse performing the initial assessment of a patient. Which action by the student nurse needs correction? A) The nurse offers a glass of water to the patient. B) The nurse avoids direct eye contact with the patient. C) The nurse checks the name on the patient's wristband. D) The nurse performs hand washing in front of the patient. B) The nurse avoids direct eye contact with the patient. Which areas does the nurse assess by using a penlight during an adolescent's physical examination? A) Buccal mucosa B) Palpebral slant C) Nares and septum D) Corneal light reflex E) Tympanic membranes A) Buccal mucosa C) Nares and septum D) Corneal light reflex The nurse is preparing a care plan for a patient with a renal disorder. Which data should the nurse consider in order to develop an effective care plan? A) The data present in the patient's chart B) The patient's feelings about the illness C) The signs and symptoms reported by the patient D) The findings in the laboratory and diagnostic reports E) The assumptions made by the patient's family members A) The data present in the patient's chart B) The patient's feelings about the illness C) The signs and symptoms reported by the patient D) The findings in the laboratory and diagnostic reports What should the nurse determine while assessing a patient's personal hygiene? A) Whether the patient is able to shave B) Whether the patient has normal body weight C) Whether the patient is able to apply makeup D) Whether the patient is able to comb hair properly E) Whether the patient has a normal urine voiding frequency A) Whether the patient is able to shave C) Whether the patient is able to apply makeup D) Whether the patient is able to comb hair properly What assessment should the nurse include during the examination of a young child's head and face? A) Assessing the fontanels B) Palpating the suture lines C) Inspecting the size of the head D) Noting the molding of the head C) Inspecting the size of the head The health care provider has instructed the nurse to start ambulation for a bedridden patient. What should be the first step while helping the patient to ambulate? A) Assisting the patient to sitting position B) Asking the patient to stand up independently C) Checking if the patient needs any assistance while standing up D) Ensuring that the patient is on a sequential compression lower limb device A) Assisting the patient to sitting position Which factors can prevent electronic health record (EHR) adoption in a hospital? A) The hospital may have limited resources. B) The hospital may have limited infrastructure. C) The hospital staff may find the training difficult. D) The hospital may have a small number of patients. E) The hospital may have an effective paper record system. A) The hospital may have limited resources. B) The hospital may have limited infrastructure. While examining a patient, the nurse finds that the patient's blood pressure is 110/80 mm Hg, the heart rate is 70 beats/minute, the urine output is 180 mL/8 hours, and the respiratory rate is 28 breaths/minute. Which finding indicates that the patient requires immediate attention? A) Heart rate B) Urine output C) Blood pressure D) Respiratory rate B) Urine output When the nurse is organizing patient data for verbal communication, which of the nurse's questions would reflect element "B" of the Situation, Background, Assessment, and Recommendation (SBAR) framework? A) "What interventions may help the patient?" B) "What is happening to the patient right now?" C) "What are the patient's current medications?" D) "Which body system is affected in the patient?" C) "What are the patient's current medications?" The student nurse is caring for a patient with a urinary catheter. The nurse instructed the student nurse to monitor the patient's blood pressure, pulse rate, and rate of respiration every hour. Which additional parameter would the student nurse monitor in the patient every time while determining these parameters? A) Skin integrity B) Blood glucose level C) Red blood cell count D) Color and quantity of urine D) Color and quantity of urine Which action by a nurse is appropriate before beginning a physical examination of a client?Wash hands. Prior to conducting a physical examination of a patient, the nurse should obtain and check needed equipment, identify how to maintain patient privacy during the examination, and wash hands before beginning the examination.
Which position is usually recommended when the nurse is assessing a patient's heart and lungs?In the sitting position, it is easy to examine the anterior and posterior thorax, lungs, heart, and vital signs. This is because sitting provides full expansion of lungs and better visualization of symmetry of upper body parts.
Which are reasons for a nurse to perform a nursing assessment of a client quizlet?Terms in this set (71). To obtain baseline information.. To develop a plan for nursing care.. To evaluate effectiveness of interventions.. To receive reimbursement for services provided.. To determine the presence of disease pathology.. Which factors should a nurse consider before performing an inspection during a physical exam?Which factors should a nurse consider before performing an inspection during a physical exam? -Ample lighting. -Time available for the exam. -Adequate exposure of anatomical surfaces.
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Which action by the student nurse performing a cardiovascular assessment requires correction?
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