Which of the following would be the most appropriate for you as the student
nurse to do next? Right Ans - Perform a Glasgow Coma Score (GCS).
When performing a physical examination of Winnie which of the following
would be most appropriate? Right Ans - Try to minimise position changes
for her.
Which test would be most appropriate to perform when assessing Winnies
eye muscle strength Right Ans - Extra ocular movement test.
Which of the following nursing assessments will give you objective data
relating to the functioning of Winnies cerebellum? Right Ans -
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?
Right Ans - Lock the fingers together and pull against each other.
Winnies patellar reflex is normal. Which of the following is the correct
number to document this? Right Ans - 2+
Which of the following would be the most likely sign of a frontal lobe
contusion? Right Ans - Difficulty speaking
For which patient condition would you most likely expect a capillary refill
time longer than two seconds? Right Ans - Peripheral vascular disease.
Which one of the following is a myth about pain in the older adult? Right
Ans - 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? Right Ans -
Auscultatory gap.
, You are having difficulty auscultating Joyce's heart sounds, specifically S1 and
S2. Which of the following would help? Right Ans - Palpate the carotid
pulse while auscultating the heart.
Which type of pain would be associated with arthritis? Right Ans - Chronic
When assessing Rangi which part of the body would you assess for the
presence of central cyanosis? Right Ans - Oral mucosa.
Which of the following processes is not required in order for effective
respiration to occur? Right Ans - Obstruction.
Which of the following is a warning sign of acute respiratory distress?
Right Ans - 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? Right Ans - Be alert to the patient's
comfort and offer rest periods.
When auscultating the apices of Rangi's lungs, where would you place your
stethoscope? Right Ans - Slightly above the clavicle.
Which of the following describes a wheeze? Right Ans - High-pitched,
musical sounds heard primarily during expiration
When performing a comprehensive assessment, which part of the body would
you assess for information about the motor function of cranial nerve VII?
Right Ans - 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?
Right Ans - 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?
Right Ans - Consensual response.
Which of the following questions will help you evaluate Mrs Jones for a
hearing impairment? I."Do you have a problem hearing over the telephone?"