BNMN 501 Final Exam - Questions and Answers

BNMN 501 Final Exam - Questions and Answers Mrs. Bagos was unresponsive for 30 seconds, and became conscious again after 5 minutes. What is the next step to take as a student nurse? Perform a Glasgow Coma Score (GCS). When performing a physical examination of Winnie which of the following would be most appropriate? Try to minimize position changes for her. Which test would be most appropriate to perform when assessing Winnie’s eye muscle strength and cranial nerve function? Extra ocular movement test. Which of the following nursing assessments will give you objective data relating to the functioning of Winnies cerebellum? Coordination The registered nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have Winnie do? Lock the fingers together and pull against each other. Winnie’s patellar reflex is normal. Which of the following is the correct number to document this? 2+ Which of the following would be the most likely sign of a frontal lobe contusion? Difficulty speaking. Mrs. Joyce Collins: Blood pressure check. History of myocardial infraction, has rheumatoid arthritis and also type 2 diabetes. Has increasing right calf pain on walking, feet always cold, lesion on right lower leg that won’t heal: For which patient condition would you most likely expect a capillary refill time longer than 2 seconds? Peripheral vascular disease. Which one of the following is a myth about pain in the older adult? Elderly people who are confused or cognitively impaired do not have pain. Which of the following represents the break in sounds between the first and second sounds when auscultating Joyce's blood pressure? Auscultatory gap. You are having difficulty auscultating Joyce's heart sounds, specifically S1 and S2. Which of the following would help? Palpate the carotid pulse while auscultating the heart. Which type of pain would be associated with arthritis? Somatic. Rangi Shand: 3 days of clear nasal discharge with slight intermittent cough, was awake last night with wheezing: When assessing Rangi which part of the body would you assess for the presence of central cyanosis? Oral mucosa. Which of the following processes is not required in order for effective respiration to occur? Obstruction. Which of the following is a warning sign of acute respiratory distress? A blue tinge to the mouth and lips. Which of the following would be most important for you to remember when auscultating Rangi's posterior chest? Listen at each site for at least one complete respiratory cycle. When auscultating the apices of Rangi's lungs, where would you place your stethoscope? Slightly above the clavicle. Which of the following describes a wheeze? High-pitched, musical sounds heard primarily during expiration. Mrs. Jones: Macular degeneration, past 2 months she doesn’t seem well-groomed and house is not clean like it used to be. She is lonely, hearing and sight are getting worse: When performing a comprehensive assessment, which part of the body would you assess for information about the motor function of cranial nerve VII? Head and face. You are preparing to assess Mrs. Jones' distance visual acuity. Given that she wears reading glasses which of the following would be most appropriate? Ask Mrs. Jones to remove her glasses before testing. During Mrs. Jones' ocular exam you shine a light into one eye and the pupil of the other eye constricts. What of the following do you interpret this as? Consensual response. Which of the following questions will help you evaluate Mrs. Jones for a hearing impairment? a. “Do you have a problem hearing over the telephone” b. “Do people complain that you turn the TV volume up too high” c. “Do you misunderstand what others are saying and respond inappropriately” d. “Do many people you talk to seem to mumble (or not speak clearly)? All of the above. If Mrs. Jones has difficulty hearing high-pitched sounds, which of the following would you document this finding as? Presbycusis. Mrs. Jones has asked you to present an educational class to her garden club about vision and eye health. As part of the presentation you explain how visual perception occurs. Which of the following would you include in the explanation? Involved light rays striking the retina. Mrs. Jones asks you why cerumen is important because it "just clogs up the ear anyway". Which response would be most appropriate? "It helps keep the tympanic membrane soft." Molly: Itchy left eye and hurts when she blinks, also bloodshot. Worsened overnight dry and crusty with yellow discharge, right eye showing similar symptoms: Nurses should be aware of the verbal and non-verbal ways patients communicate discomfort. What would be an appropriate assessment tool to use with Molly? A faces pain scale. How would you advise Molly and her mum as to the best way to reduce the risk of spreading the disease? Hand hygiene. Which of the following would be the most accurate nursing diagnosis for Molly? Pain related to exudate in left eye. You are aware that it is important to break the chain of infection, which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a patient? Changing soiled dressing. Which of the following statements about PPE is incorrect? You do not need to perform hand hygiene if you have worn gloves. Which of the following is not an element in the chain of infection? Formation of immunoglobulin. Mr. James London: Admitted to an aged care facility. History of Parkinson’s disease which is controlled with Sinemet, has a reddened area on his sacrum: Mr. London has very limited mobility, how often should you assist him to change position to prevent the development of a pressure injury?