NURS 125 Final Examination test with correct marking scheme, Exams of Nursing

Download NURS 125 Final Examination test with correct marking scheme and more Exams Nursing in PDF only on Docsity! NURS 125 Final Examination test with correct marking scheme A patient on a medical- surgical floor reports having shortness of breath. The nurse needs to conduct which type of assessment? - Problem based For which patient is a shift assessment indicated? A. the person being admitted to long-term care B. The person who is at a health fair C. The person who is complaining of chest pain D. he person who had abdominal surgery yesterday - d Which of the following examples represents a secondary prevention level of health promotion? A. Immunizations B. Hypertension management C. Blood pressure screenings D. Exercise - c What is objective data? - Data you can observe Which of the following is a correct statement regarding the technique LIGHT palpation? Light palpation is A. used to determine organ size. B. performed using the fingertips. C. performed by pressing down on a patient's body to a depth of 4 cm. D. used to assess tenderness. - D A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is too narrow (small). How accurate will this patient's blood pressure be using this blood pressure cuff? - Higher than the actual value During a physical assessment of an elderly adult, the nurse has difficulty palpating the patient's dorsalis pedals pulses. Which piece of equipment would be helpful during this assessment? - Doppler An example of Primary prevention of Health Promotion is: - immunizations What is subjective data? - Data that the patient reports O position an adult's ear correctly for a tympanic membrane temperature, the nurse should - pull upward on the cartilage of the ear Which actions by the nurse results in the patient's blood pressure measurement being falsely high? 1. Deflating the blood pressure cuff too rapidly 2. Positioning the patient's arm above the level of the heart 3. Using a blood pressure cuff that is too narrow for the upper arm 4. Wrapping the blood pressure cuff too loosely 5. Reflating the blood pressure cuff before it is completely deflated - 3, 4, and 5 The difference between the systolic pressure and the diastolic pressure is known as the - pulse pressure A nurse calculates a patient's body mass index (BMI) as 33. This measurement indicates which class of weight? - class 1 Which of the following are influential in a patient's basal metabolic rate (BMR)? Select all that apply. A. Infection B. ethnicity C. Illness D. Ingestion of food E. activity level - A, C, D, and E What are macronutrients? - Carbs, fats, and proteins What percentage of the body is water? - 60-70% Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake? A. 24 hour recall B. Food diary C. comprehensive diet history D. calorie count - 24 hour recall While inspecting the skin, a nurse notices a lesion on the patient's upper right arm. What is the best way to document the size of this lesion? - measure it in cm What signs of cyanosis does a nurse inspect for in a dark-skinned patient? - Ashen gray mucous membranes and nail beds A patient is assessed with poor skin turgor as the skin is observed to recede slowly back into place. This would be charted as: - tenting C. Pain when legs are dependent that is relieved when legs are elevated D. Pitting edema of one or both feet or legs. - A When inspecting a patient's abdomen, the nurse notes which finding as abnormal? A. A centrally-located umbilicus. B. Faint, fine vascular network C. Marked visible pulsations D. Soft, flat abdomen with skin that is lighter in color than the arms and legs - c A nurse notices abdominal distention when inspecting a patient's abdomen. What action can the nurse take next to gain further objective data? A. Ask the patient to cough while lying supine. B. Assist the patient to turn on to the left side and then the right side. C. Use the fingertips to sharply strike one side of the abdomen. D. Place a measuring tape around the superior iliac crests. - D In assessing range of motion in a patient's ankle, the nurse knows to have the patient dorsiflex the foot. The nurse asks the patient to A. turn the sole of the foot medially. B. move the foot so the toes are pointed downward. C. move the foot so the toes are pointed toward the face, upwards D. bring the heel back toward the back of the thigh - c What technique does the nurse use to test bicep muscle strength? A. The patient pushes up against the nurse's hand to abduct the bicep muscle. B. The patient places their hands behind the head with elbows out. C. the patient extends the arm while the nurse resists by pushing it to a flexed position. D. The patient tries to flex the arm while the nurse tried to extend the patient's forearm. - D The nurse is assessing the range of motion of the patient's hip joint. The expected range for abduction is up to - 45 degrees A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these finding with which area of the brain? A. thalamus B. temporal lobe C. parietal lobe D. frontal lobe - d What is the earliest indication of impaired cerebral function? A. change in level of consciousness B. loss of deep tendon reflexes C. paralysis on one side of the body D. unequal pupils - a Which cranial nerve is responsible for the voluntary muscles for swallowing and phonation? - Glossopharyngeal (IX) Which manifestations does a nurse correlate with a patient with suspected meningitis? Select all that apply. A. tremors of the hands B. Confusion, agitation, and irritability C. Aphasia D. Stiff neck E. Severe headache - B, D, and E. Which assessment finding of older adult patients indicates expected respiratory function? A. Flaccidity of the chest wall B. Similar breath sounds, as for younger adults C. Increased elasticity D. Shallow breathing - b During inspection of the mouth of an older adult, a nurse notices which finding as an expected change associated with aging? A. Red, edematous tongue with erosions B. A receding gum line C. Ulcerations of the mucosa D. Fissures at the corners of the mouth - b In assessing the nails of an older adult, which finding does a nurse expect to find? - Thick and brittle nails In assessing the external eyes of an older adult, a nurse documents which finding as abnormal? A. Gray-white circle where the cornea and the sclera merge B. Brown spots near the limbus in both eyes C. Lack of luster of the eye and dry bulbar conjunctiva D. Lower lid drops away from the globe - d What is the best color for nurses to select when designing educational materials for older adults? - Black Which finding is an expected age-related finding for an 80 year old female? A. Back pain B. Loss of height C. Herniated disk in the spine D. A re-distribution of subcutaneous fat to the face and extremities from the abdomen and hips - b When performing a shift assessment on patients in the hospital setting it is important to remember that A. the information that is exchanged among nurses during the shift report can take the place of performing the shift assessment. B. both the patient and the equipment used in treatment are assessed. C. the examination sequence must always be the same for each patient. D. the patient's past medical history is not relevant information at this time. - B Development of which complication is considered a never event (A medical error that should never occur). A. pressure ulcer obtained after admission to hospital. B. thrombophlebitis C. atelectasis D. fever - a What data do nurses collect when assessing a patient's wound? Select all that apply. A. Skin turgor B. Presence of pulsation C. Color of drainage D. Width, length, and depth E. Tissue type F. Wound color - C, D, E, and F When performing a neurologic assessment of a patient, the nurse discovers that shouting and shaking are necessary to arouse the patient enough to assess the neurological status. After the patient answers questions about who he is and squeezes the nurse's hand as requested, he returns to "sleep". How does the nurse document this patient's level of consciousness? A. Lethargic B. Stupors C. Semi comatose D. Obtunded - D. What evidence based practice is the best indicator that there is a return of gastrointestinal motility after abdominal surgery? - Return of flatus and passage of first BM Lethargic - sluggish Stupors - partial unconsciousness In teaching a patient about breast self-examination, why does the nurse emphasize palpation of the axillary areas? A. Because supporting ligaments in this area may present as tissue changes B. Because most lymph draining from the breast flows through this area C. Because some patients avoid this area because of tenderness