Chapter 27 and 10 - Fundamentals

A nurse on a medical-surgical unit is caring for a group of patients. For which patient will the nurse perform a focused assessment?

• newly admitted

• recent application of a wrist cast

• signs of acute respiratory distress

• post-abdominal surgery without complications

1. A nurse admitting a patient to a long-term care facility performs a functional assessment. Which questions will the nurse include as part of the assessment? Select all that apply.

• “Are you able to dress yourself?”

• “Do you have a history of smoking?”

• “What is the problem for which you are seeking care?"

• “Do you prepare your own meals?”

• “Do you manage your own finances?”

1. A nurse in the neurology clinic is assessing a patient’s eyes for extraocular movements. Which correctly describes the procedure for this test?

• Ask the patient to sit about 3 ft away, facing the nurse.

• Have the patient follow a penlight held 1 ft from their face slowly through the cardinal positions.

• Move a penlight in concentric circular motion in front of the patient’s eyes.

• Ask the patient to cover one eye with a hand or index card.

1. A nursing student is learning to perform physical assessments. When will the student use the technique of palpation? Select all that apply.

• 1. Assessing temperature of a patient’s feet

• 1. Counting the apical pulse

• 1. Assessing for skin turgor

• 1. Evaluating lymph nodes

• 1. Assessing for dullness over a tumor

1. When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?

• 1. Jaundice

• 1. Cyanosis

• 1. Erythema

• 1. Pallor

1. The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing assessments can the nurse perform with the patient in this position? Select all that apply.

• Assessing the abdomen

• 1. Taking peripheral pulses

• 1. Performing a breast examination

• 1. Auscultating the heart

• 1. Assessing vital signs

1. A school nurse assesses adolescents’ visual acuity using a Snellen eye chart. Which explanation does the nurse provide to the student whose vision is 20/40 in both eyes?

• “They see better than 50% of people.”

• 1. “Double vision is present.”

• 1. “Vision is less than normal.”

• 1. “They have normal vision.”

The nurse is caring for a patient experiencing bronchospasm due to an exacerbation of asthma. During auscultation, the nurse anticipates the presence of which breath sound?

• Sibilant

• 1. Wheezes

• Rhonchi

• Crackles

A nurse in the emergency department is using the Glasgow coma scale to assess a patient who was struck in the head and upper body with a baseball bat. Based on the information in the neurologic assessment, what numerical value will the nurse assign?

Neurologic assessment:

The patient opens his eyes to painful stimulus, does not speak, and withdraws to painful stimulus. Unable  to assess orientation to person, time, and place.

• 3

• 7

• 11

• 15

1. A nurse is caring for a patient with exacerbation of COPD and pneumonia. When auscultating the lungs, coarse expiratory, low-pitched, and continuous sounds that clear with coughing are present. How will the nurse document this breath sound in the electronic health record?

• 1. Rhonchi

• 1. Bronchovesicular breath sounds

• 1. Stridor

• 1. Bronchial breath sounds