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
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:
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)
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
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:
Gown
Eyewea
, r
Gloves
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
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:
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)
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
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:
Gown
Eyewea
, r
Gloves
