Question 1
pts
The general survey begins a review of the patient’s primary health problems and
evaluation of the patient’s vital signs, height and weight, general behavior, and
appearance. It also provides information about the patient’s illness, hygiene, skin
condition, body image, and emotional state. Which of the following cannot be delegated
to nursing assistive personnel?
Measuring the patient’s height and weight
Reporting subjective signs and symptoms
Correct!
Obtaining initial vital signs
Monitoring I&O
You cannot delegate the general survey to nursing assistive personnel (NAP). The
nurse directs NAP to obtain vital signs (not the initial set, but subsequent measurements
if patient is stable).
The nurse directs NAP to report a patient’s subjective signs and symptoms to the nurse,
to measure the patient’s height and weight, and to monitor oral intake and urinary
output.
Question 2
pts
The nurse is caring for a patient who is recovering from an acute myocardial infarction.
While providing cardiac education, the nurse realizes that the patient needs more
education when he:
Correct!
States that he will take his medication when he has chest pain or when his heart rate is
greater than 100
Describes the schedule, dosage, and purpose of his medication
Describes changes in his behavior that may improve cardiovascular function
,Describes the benefits of taking his medication regularly
The patient should not take medications for cardiovascular function intermittently.
Medication should be taken on the regular prescribed schedule to prevent additional
cardiac events.
Describing changes in his behavior that may improve his cardiovascular function
indicates that the patient understands steps he may take to improve his own health. The
ability to accurately describe the schedule, dose, and purpose of his medication
indicates that the patient understands his treatment. Understanding the benefits of
taking his medication regularly should improve patient compliance with therapy.
Question 3
pts
The patient is diagnosed with Bell’s palsy. The nurse assesses the patient and notices
drooping of the patient’s right eye and the right side of his mouth. When the functions of
the following nerves are compared, the most likely cause of these symptoms would be a
dysfunction of:
The trigeminal nerve (CN V)
The glossopharyngeal nerve (CN IX)
Correct!
The seventh cranial nerve
The oculomotor nerve (CN III)
Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have patient frown,
smile, puff out cheeks, and raise eyebrows. Expressions should be symmetrical; Bell’s
palsy causes drooping of upper and lower face; cerebrovascular accident (CVA) causes
asymmetry.
Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to
symmetrical areas of face. Sensations should be symmetrical; unilateral decrease or
loss of sensation is possibly due to CN V lesion or a lesion in higher sensory pathways.
Assess cranial nerve CN III (oculomotor), IV (trochlear), and VI (abducens) by
assessing extraocular movement (EOM) functioning. Ask patient to follow the
movement of your finger through the six cardinal positions of gaze; measure pupillary
reaction to light reflex and accommodation using a penlight. These cranial nerves are
most likely to be affected by increasing intracranial pressure (ICP), which causes
,change in the pupil response or the pupil size; sometimes pupils change shape (more
oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired
swallowing; damage to CN X causes loss of gag reflex, hoarseness, and nasal voice.
When the palate fails to rise and the uvula pulls toward the normal side, this indicates a
unilateral paralysis.
Question 4
pts
Which patient position maximizes the nurse’s ability to assess the patient’s body for
symmetry?
Supine
Dorsal recumbent
Prone
Correct!
Sitting
Sitting upright provides full expansion of lungs and allows better visualization of
symmetry of upper body parts.
The supine position maximizes the nurse’s ability to assess pulse sites. The prone
position is used only to assess extension of the hip joint. The dorsal recumbent position
is used for abdominal assessment because it promotes relaxation of abdominal
muscles.
Question 5
pts
Before entering the room of a client on isolation where all protective barriers are
required, the nurse first puts on the:
Correct!
Gown
Eyewear
, Gloves
Mask/respirator
Apply the gown first, making sure that it covers all outer garments. Pull sleeves down to
the wrist. Tie securely at the neck and waist.
Apply gown first, making sure that it covers all outer garments. Pull sleeves down to the
wrist. Next apply either a surgical mask or a fitted respirator around the mouth and
nose. Goggles or a face shield is put on after the gown and mask are applied. Gloves
are put on last.
Question 6
pts
Droplet Precautions will be instituted for the patient admitted to the infectious disease
unit with:
Measles
Herpes simplex
Pulmonary TB
Correct!
Streptococcal pharyngitis
Droplet Precautions are instituted when droplets are larger than 5 m, as in the case of
streptococcal pharyngitis.
Contact Precautions are instituted for herpes simplex. Airborne Precautions are
instituted for pulmonary TB and measles.
Question 7
pts
The nurse needs to transfer the patient from the bed to the stretcher. The patient is
unable to assist. Of the following, which would be the best technique for transferring the
patient?
Using the three-person lift technique
pts
The general survey begins a review of the patient’s primary health problems and
evaluation of the patient’s vital signs, height and weight, general behavior, and
appearance. It also provides information about the patient’s illness, hygiene, skin
condition, body image, and emotional state. Which of the following cannot be delegated
to nursing assistive personnel?
Measuring the patient’s height and weight
Reporting subjective signs and symptoms
Correct!
Obtaining initial vital signs
Monitoring I&O
You cannot delegate the general survey to nursing assistive personnel (NAP). The
nurse directs NAP to obtain vital signs (not the initial set, but subsequent measurements
if patient is stable).
The nurse directs NAP to report a patient’s subjective signs and symptoms to the nurse,
to measure the patient’s height and weight, and to monitor oral intake and urinary
output.
Question 2
pts
The nurse is caring for a patient who is recovering from an acute myocardial infarction.
While providing cardiac education, the nurse realizes that the patient needs more
education when he:
Correct!
States that he will take his medication when he has chest pain or when his heart rate is
greater than 100
Describes the schedule, dosage, and purpose of his medication
Describes changes in his behavior that may improve cardiovascular function
,Describes the benefits of taking his medication regularly
The patient should not take medications for cardiovascular function intermittently.
Medication should be taken on the regular prescribed schedule to prevent additional
cardiac events.
Describing changes in his behavior that may improve his cardiovascular function
indicates that the patient understands steps he may take to improve his own health. The
ability to accurately describe the schedule, dose, and purpose of his medication
indicates that the patient understands his treatment. Understanding the benefits of
taking his medication regularly should improve patient compliance with therapy.
Question 3
pts
The patient is diagnosed with Bell’s palsy. The nurse assesses the patient and notices
drooping of the patient’s right eye and the right side of his mouth. When the functions of
the following nerves are compared, the most likely cause of these symptoms would be a
dysfunction of:
The trigeminal nerve (CN V)
The glossopharyngeal nerve (CN IX)
Correct!
The seventh cranial nerve
The oculomotor nerve (CN III)
Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have patient frown,
smile, puff out cheeks, and raise eyebrows. Expressions should be symmetrical; Bell’s
palsy causes drooping of upper and lower face; cerebrovascular accident (CVA) causes
asymmetry.
Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to
symmetrical areas of face. Sensations should be symmetrical; unilateral decrease or
loss of sensation is possibly due to CN V lesion or a lesion in higher sensory pathways.
Assess cranial nerve CN III (oculomotor), IV (trochlear), and VI (abducens) by
assessing extraocular movement (EOM) functioning. Ask patient to follow the
movement of your finger through the six cardinal positions of gaze; measure pupillary
reaction to light reflex and accommodation using a penlight. These cranial nerves are
most likely to be affected by increasing intracranial pressure (ICP), which causes
,change in the pupil response or the pupil size; sometimes pupils change shape (more
oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired
swallowing; damage to CN X causes loss of gag reflex, hoarseness, and nasal voice.
When the palate fails to rise and the uvula pulls toward the normal side, this indicates a
unilateral paralysis.
Question 4
pts
Which patient position maximizes the nurse’s ability to assess the patient’s body for
symmetry?
Supine
Dorsal recumbent
Prone
Correct!
Sitting
Sitting upright provides full expansion of lungs and allows better visualization of
symmetry of upper body parts.
The supine position maximizes the nurse’s ability to assess pulse sites. The prone
position is used only to assess extension of the hip joint. The dorsal recumbent position
is used for abdominal assessment because it promotes relaxation of abdominal
muscles.
Question 5
pts
Before entering the room of a client on isolation where all protective barriers are
required, the nurse first puts on the:
Correct!
Gown
Eyewear
, Gloves
Mask/respirator
Apply the gown first, making sure that it covers all outer garments. Pull sleeves down to
the wrist. Tie securely at the neck and waist.
Apply gown first, making sure that it covers all outer garments. Pull sleeves down to the
wrist. Next apply either a surgical mask or a fitted respirator around the mouth and
nose. Goggles or a face shield is put on after the gown and mask are applied. Gloves
are put on last.
Question 6
pts
Droplet Precautions will be instituted for the patient admitted to the infectious disease
unit with:
Measles
Herpes simplex
Pulmonary TB
Correct!
Streptococcal pharyngitis
Droplet Precautions are instituted when droplets are larger than 5 m, as in the case of
streptococcal pharyngitis.
Contact Precautions are instituted for herpes simplex. Airborne Precautions are
instituted for pulmonary TB and measles.
Question 7
pts
The nurse needs to transfer the patient from the bed to the stretcher. The patient is
unable to assist. Of the following, which would be the best technique for transferring the
patient?
Using the three-person lift technique
