General Survey, Thoracic, Head/Neck, and Head-to-Toe Assessments

Front

What color are oranges?

Back

Orange

Front

When percussing in an abdominal assessment, which quadrant makes a dull sound and which quadrant would you auscultate first?

Back

RUQ is typically dull; Begin with the RLQ

Front

"Gurgling" and "swishing" are words a nurse could use to describe what characteristic of abdominal sounds?

Back

Quality

Front

A nurse is assessing a patient who reports abdominal pain. Which of the following is considered subjective data? The patient states, “I feel a sharp pain in my upper abdomen.”

Back

The patient states, “I feel a sharp pain in my upper abdomen.”

Front

During the general survey of a patient admitted for heart disease, which finding should the nurse document as an abnormal/concerning finding? A blood pressure of 119/78, A BMI of 31.0, Skin is warm, dry, and intact, An oral temperature of 37.5°C

Back

A BMI of 31.0

Front

A nurse is assessing a patient who reports chest pain. The patient reports that their pain extends to their left shoulder, feels like an 8/10, and it started about 2 weeks ago. Which components of PQRST has the patient stated about their pain?

Back

S, T, R

Front

A nurse is performing an abdominal assessment on a patient reporting pain. What is the correct sequence the nurse should assess?

Back

Inspect, Auscultate, Percuss, Palpate

Front

A patient arrives at the ED one morning complaining of hearing loss. Which of the following actions would be part of a proper assessment of this condition?

1. Place a vibrating tuning fork against the patient’s mastoid processes, the vertex of his head, and next to his ears

,

1. Snap her fingers at varying distances from his ears while the patient closes his eyes

,

1. Utilize a Snellen chart with the patient standing 20 feet away from it

,

1. Place a stable tuning fork against his mandible and on the back of his head

Back

Place a vibrating tuning fork against the patient’s mastoid processes, the vertex of his head, and next to his ears

Front

A nursing student is practicing some new skills at her clinical site. In which of the following cases is she demonstrating proper technique? First donning gloves between the auscultation and percussion steps of a thoracic assessment, Using her stethoscope to palpate for abdominal masses and tenderness, Palpating a patient’s temperature with the back of her hand, Ensuring to turn on all of the room’s lights before using her penlight to assess cranial nerves

Back

Palpating a patient’s temperature with the back of her hand.

Front

When collecting an adult patient’s vital signs a nurse notices that one value is not WNL. Which of the following findings should she keep an eye on? 25 breaths per minute

Back

25 breaths per minute is the value that is not WNL.