N1J02 1st Review 2023

1. What are the three neurological functions assessed by the Glasgow coma scale?

• Eye response, muscle strength, sensation

• eye response, best motor response and best verbal response

• pupil size and reaction to light and level of consciousness

• orientation, muscle strength and pupil reaction to light

A person's mental status has been documented as orientated X 3. This means…

• The individual can correctly identify taste, odors, and texture.

• The individual can clearly articulate and appropriately communicate

• The individual can correctly identify time, place and person.

• The individual is awake, alert, and aware of environment.

Palpation at the upper surface of the foot reveals the status of which peripheral pulse?

• Femoral

• Dorsalis pedis

• Posterior tibial

• Dorsal plantar

During a cardiac examination the nurse can best hear the S1 heart sound by placing the stethoscope at the client’s

• Base of the heart

• Pulmonic valve area

• Apex of the heart

• Second left intercostal space

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first:

• Palpate the incision site

• Auscultate for bowel sounds

• Percuss for tympany

• Inspect the abdominal area

During a physical examination of an adult client, the nurse is preparing to auscultate the client’s abdomen to listen for bowel sounds. The nurse should:

• Palpate the abdomen before auscultation

• Listen in each quadrant for 15 seconds

• Use the diaphragm of the stethoscope

• Begin auscultation in the left upper quadrant

An abnormal sensation of burning or tingling is best described as:

• paraesthesia

• paralysis

• paresis

• paraphasia

You notice Heberden’s and Bouchard’s on your patient's fingers. These nodes are hard and nontender, and are associated with

• Osteoarthritis

• Dupuytren’s contracture.

• Rheumatoid arthritis

• meta-carpophalageal bursitis

When testing for muscle strength, the examiner should:

• observe muscles for the degree of contraction when the individual lifts a heavy object

• apply an opposing force when the individual puts a joint in flexion or extension

• measure the degree of force that it takes to overcome joint flexion or extension

• estimate the degree of flexion and extension in each joint

The first heart sound is produced by the:

• closure of the semilunar valves

• closure of the atrioventricular (AV) valves

• S1 heart sound

• S2 heart sound