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WorksheetsFundamentals Final
Total questions: 108
Worksheet time: 2hrs 31mins
A newly licensed nurse is attempting to insert a nasogastric tube but incorrectly places it in the patient's lung, causing a pneumothorax. The patient requires emergent chest tube insertion. Which term best describes the nurse's action?
Assault
Battery
Malpractice
Negligence
According to the Standards of Nursing Practice, which action is the nurse's primary responsibility when administering a new medication?
Documenting the patient's vital signs before and after administration.
Evaluating the patient's understanding of the medication's purpose.
Delegating the task to a licensed practical nurse (LPN).
Ensuring the patient has the right to refuse the medication.
The nurse is preparing to administer an oral medication to a patient who is deaf and uses sign language. Which intervention is the most appropriate to ensure patient safety and understanding of the medication?
Writing the medication's name and side effects on a whiteboard.
Using an authorized sign language interpreter to facilitate communication.
Asking the patient's family member to translate the information.
Demonstrating the action of swallowing the pill and pointing to the drug name.
A patient with a history of recurrent falls is prescribed a physical restraint. Before applying the restraint, which action must the nurse prioritize to align with the concept of patient-centered care and patient safety?
Reviewing the prescriber's order for the specific type of restraint.
Checking the patient every 15 minutes for neurovascular compromise.
Exhausting all less restrictive alternatives, such as a bed alarm or sitter.
Explaining to the patient and family that restraints are mandatory for safety.
The nurse is conducting a health history interview for a middle-aged adult. The patient reports a sudden loss of appetite, fatigue, and feeling "down." Which assessment technique is the nurse using by clustering these subjective reports to form a possible diagnosis?
Data collection
Data interpretation
Finding data patterns
Validation of data
A nurse is reviewing a patient's electronic health record (EHR) and notes incomplete documentation regarding a wound dressing change. Which guideline for quality documentation is most violated?
Factual
Timeliness
Completeness
Organization
Which variation in vital signs would be considered an expected finding in a healthy 10-month-old infant compared to a healthy adult?
Lower heart rate and lower respiratory rate.
Higher systolic blood pressure and lower temperature.
Higher heart rate and higher respiratory rate.
Lower systolic blood pressure and lower temperature.
A patient is admitted with severe burns and is complaining of pain (8/10). The nursing care plan includes goals for pain management and preventing infection. Which goal is the highest priority for patient education?
Demonstrating correct hand hygiene technique before touching the burn.
Identifying foods that promote wound healing.
Verbalizing the need to report a pain level of 4/10 or greater.
Discussing the long-term prognosis for scar formation.
The nurse administers a prescribed anti-hypertensive medication to a patient. This action is an example of which type of nursing intervention?
Independent, Direct
Dependent, Indirect
Independent, Indirect
Dependent, Direct
A patient's Arterial Blood Gas (ABG) results are pH 7.28, {PaCO} 55 mmHg, and {HCO} 24 mEq/L. The nurse correctly interprets this finding as:
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
The nurse is caring for a patient who is actively dying. The patient's spouse expresses a desire for the patient to receive comfort measures but also wants their life-prolonging treatments to continue. The nurse recognizes that this patient's care is best aligned with which philosophy?
Palliative Care
Hospice Care
Curative Care
Rehabilitation
A patient reports involuntary loss of urine with sneezing, laughing, or coughing. The nurse teaches the patient Kegel exercises as an intervention for which type of urinary incontinence?
Reflex
Overflow
Stress
Urge
The nurse is preparing a sterile field for a dressing change. Which action by the nurse would require the entire field to be re-established?
The nurse touches the outer 1-inch border of the sterile drape with ungloved hands.
The nurse pours a sterile solution into a container on the sterile field from a height of 6 inches.
The patient accidentally sneezes directly over the sterile supplies.
The nurse places the dressing materials on the sterile field using sterile forceps.
A nurse is attending to a patient who has received a terminal diagnosis. The patient states, "If I can just make it to see my granddaughter graduate next month, I'll be ready to go." The nurse recognizes this statement as aligning with which stage of grief, according to Kübler-Ross?
Denial
Anger
Bargaining
Acceptance
The nurse has been working on a high-acuity medical-surgical unit for several years. Recently, the nurse has been feeling emotionally exhausted, depersonalized toward patients, and has a diminished sense of personal accomplishment. The nurse's symptoms are indicative of which condition?
Post-Traumatic Stress Disorder (PTSD)
Compassion Fatigue
Secondary Traumatic Stress
Moral Distress
The nurse is caring for a patient with a newly placed ileostomy. Which finding is an expected and normal assessment finding for this patient?
Semiformed stool passed every 2 to 3 days.
Continuous liquid, dark green to yellow-brown drainage.
Minimal output for the first 72 hours post-procedure.
The stoma appears dark blue and dry.
The nurse is caring for four patients. Which patient should the nurse assess first?
A patient scheduled for discharge who is asking for pain medication.
A patient with a new colostomy who is requesting teaching on appliance changes.
A patient with a history of heart failure who has new-onset shortness of breath and an oxygen saturation of 89%.
A patient with a surgical incision that is documented as clean, dry, and intact.
A nurse is implementing the Nursing Process to address a patient's deficient knowledge regarding a new diagnosis of diabetes. Which action represents the Evaluation phase of the process?
Reviewing the patient's medical history and current blood glucose levels.
Establishing a goal for the patient to demonstrate proper insulin injection technique by the end of the shift.
Teaching the patient the signs and symptoms of hypoglycemia.
Asking the patient to demonstrate the insulin injection technique and check their understanding.
The nurse is caring for an older adult patient who has been on prolonged bed rest. Which nursing intervention is the priority to prevent the most serious complication of immobility related to the cardiovascular system?
Performing passive range of motion (ROM) exercises four times daily.
Applying sequential compression devices (SCDs) and encouraging ankle pumps.
Administering a prescribed stool softener daily.
Teaching the patient how to deep breathe and cough every 1 to 2 hours.
The nurse needs to teach a patient how to change a complicated wound dressing at home. Which teaching method is most effective for mastering a psychomotor skill like this?
Discussion
Role-playing
Demonstration and Return Demonstration
Lecturing with visual aids
A nurse is reviewing the charting of a new admission. Which of the following documented actions could potentially be considered an act of negligence or a breach of the standard of nursing care? (Select all that apply.)
Failing to check the patient's ID band against the medication administration record (MAR) before administering a drug.
Documenting a blood pressure of 145/90 mmHg as "WNL" (within normal limits) for an adult with no history of hypertension.
Leaving the side rails down on a patient who is documented as being confused and at high risk for falls.
Administering an influenza vaccine to a patient after confirming the patient's allergy status and obtaining consent.
Delegating the task of obtaining routine vital signs to an unlicensed assistive personnel (UAP).
The nurse is caring for an older adult patient who is placed in wrist restraints due to continuously attempting to pull out their nasogastric tube. Which actions must the nurse perform according to the guidelines for physical restraints? (Select all that apply.)
Ensure the restraint is secured to the side rail of the bed, not the movable portion.
Remove the restraints completely every 2 hours to assess skin integrity and perform range of motion (ROM).
Document the assessment of the patient's neurovascular status (circulation, sensation, movement) every 15 minutes.
Renew the original written physician's order for the restraints every 4 hours for an adult patient.
Offer the patient food, fluids, and toileting every 8 hours.
A patient with a prolonged history of gastric suctioning for a bowel obstruction is at risk for developing fluid and electrolyte imbalances. Which clinical findings would indicate the patient is experiencing a relevant acid-base or electrolyte imbalance? (Select all that apply.)
ABG results: {pH} 7.50, {PaCO} 40 mmHg, {HCO} 33 mEq/L.
Serum Potassium level of 2.9 mEq/L.
Trousseau's sign and Chvostek's sign are positive.
Respiratory rate is shallow and slow (bradypnea).
The patient reports muscle weakness and decreased deep tendon reflexes.
The nurse is providing education to a patient with a newly formed colostomy. Which instructions should the nurse include in the teaching plan? (Select all that apply.)
Empty the pouch when it is approximately one-third to one-half full.
Report any stoma that appears pale, purple, or dark blue immediately to the healthcare provider.
Expect the output to be primarily liquid for the first 3 to 6 months.
Wash the peristomal skin gently with a mild, moisturizing soap and warm water, then rinse and dry thoroughly.
Cut the wafer opening so it is slightly larger (about 1/8 inch) than the stoma to prevent friction.
A nurse is monitoring a sedated patient using continuous capnography. The end-tidal carbon dioxide {EtCO} reading has steadily increased from 35 mmHg to 55 mmHg. Which nursing intervention should the nurse perform first?
Increase the patient's intravenous (IV) fluid rate.
Administer a prescribed PRN opioid analgesic.
Stimulate the patient to take a deeper breath and assess respiratory rate.
Document the finding and continue to monitor the patient closely.
The relationship between documentation and financial reimbursement for healthcare is critical. Which phrase best describes the financial consequence of poor nursing documentation, particularly within the context of Diagnosis-Related Groups (DRGs)?
It often leads to the automatic discharge of the patient.
It prevents the patient from accessing future care services.
It can result in a denial or reduction of payment from insurance or Medicare.
It requires the patient to pay out-of-pocket for all services rendered.
The nurse is performing postmortem care for a patient who died 30 minutes ago. Which action is the priority for the nurse to perform?
Remove all tubes and lines and place the body in the anatomical position.
Notify the patient's primary healthcare provider of the death.
Elevate the head of the bed to prevent pooling of blood (lividity) in the face.
Clean the patient's room and prepare the body for the family to view.
A nurse on the unit asks you (the new nurse), "Why are you wasting time educating that patient? They will just be back next week." You know that as a nurse you are __________ for that Pt and the education you provide. Your response to the nurse that you will always be consistent with your patient's care, no matter their compliance, shows you are _______________.
accountable, responsible
responsible, accountable
A medical assistant has a blood pressure cuff inflated and partially opens the valve to deflate as he listens with a stethoscope. When should he read the diastolic pressure?
When the sound disappears
When repetitive sounds begin
When the sounds change from strong to muffled
When the sounds change from swishing to sharp
What is the importance of documenting care accurately in the nursing care plan?
It is only necessary for legal reasons
It helps ensure continuity of care
It is primarily for billing purposes
It is a formality that has little impact on patient care
The primary goal of a nursing care plan is to:
Standardize care for all patients
Provide a detailed medical history
Ensure personalized, goal-oriented care
Reduce the need for direct patient interaction
What should the health care worker do if a patient shows signs of orthostatic hypotension while sitting in the dangling position?
Help the patient to lie down
Leave the patient in the dangling position
Call for help
Help the patient stand up
Why are side rails and safety straps considered restraints?
They are added to equipment to keep patients safe
A physician must order that they be used
They prevent a patient from moving freely
They touch the patient's body
Which of the following techniques should a medical assistant use to confirm a patient's understanding of insulin administration?
Observe the patient as she performs a self-demonstration
Provide the patient with written instructions
Offer the patient a website to visit for directions
Repeat the instructions to the patient
The nurse is assessing the vital signs of a 2-year-old child. Which finding, when compared to a healthy adult, would warrant immediate further investigation?
Respiratory rate of 28 breaths/min.
Heart rate of 110 beats/min.
Blood Pressure of 140/90 mmHg.
Temperature of 99.5 taken rectally.
A patient who is immobile is at high risk for skin breakdown. The nurse delegates a bath to the Unlicensed Assistive Personnel (UAP). Which instructions are most critical for the nurse to give the UAP to ensure proper hygiene and prevention of immobility complications? (Select all that apply.)
"Give the patient a full bed bath using only mild, non-scented soap."
"Avoid massaging any reddened areas over bony prominences."
"Ensure the linens are dry and free of wrinkles after the bath."
"Turn and reposition the patient to a 30 degree lateral position every two hours."
"Perform range of motion exercises on all extremities after the bath."
The nurse is caring for the spouse of a patient who died unexpectedly. The spouse repeatedly says, "I can't believe this happened. It feels like a bad dream." The nurse recognizes the spouse is experiencing which type of grief?
Normal Grief
Anticipatory Grief
Disenfranchised Grief
Complicated Grief
Which actions performed by the nurse are considered indirect nursing interventions? (Select all that apply.)
Administering a prescribed injection.
Documenting the patient's intake and output in the electronic health record.
Consulting with a physical therapist about the patient's mobility plan.
Providing the patient with a full bed bath.
Sterilizing surgical equipment in the central supply unit.
A nurse is providing care for an older adult patient who reports straining and hard, dry stool. Which nursing interventions are appropriate to include in the plan of care for the patient's constipation? (Select all that apply.)
Encourage a fluid intake of 2,000 to 3,000 mL per day, unless contraindicated.
Administer a bulk-forming laxative, such as psyllium, as ordered.
Suggest avoiding all high-fiber foods for the next 24 hours to reduce bulk.
Assist the patient to the toilet or commode 30 minutes after meals.
Limit the patient's daily physical activity to conserve energy.
When performing a physical assessment of a patient with a newly diagnosed small bowel obstruction, the nurse would expect to find which characteristic bowel sounds?
Absent or minimal sounds.
Normal, active sounds.
High-pitched and hyperactive (borborygmi) proximal to the obstruction.
Low-pitched, hypoactive sounds.
The nurse is teaching a patient about self-care for a descending colostomy. The nurse should include which information regarding the expected stool consistency?
Continuous liquid, highly acidic drainage.
Formed or soft, paste-like stool.
Watery, mucous-like stool passed infrequently.
Semiformed stool with undigested particles.
A patient with prolonged, severe diarrhea is admitted. The nurse reviews the patient's ABG results: {pH} 7.29, {PaCO} 40 mmHg, {HCO} 18 mEq/L. The nurse correctly interprets this finding as:
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
A nurse is caring for older adult clients in an assisted living facility. The nurse encourages the clients to eat diets that are high in fiber to prevent constipation. In which way would the nurse assist the clients to plan a menu to ensure that their dietary intake is rich in fiber?
Plan meals high in carbohydrates.
Include fish and shellfish in the diet.
Eat fruits and vegetables daily.
Increase the amount of dairy in the diet.
A client comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. Which assessment techniques and diagnostic studies should the nurse use?
Bowel sounds and routine urinalysis
Lung sounds and chest x-ray
Bowel sounds and stool sample
Lung sounds and sputum sample
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?
high intake of fiber
constant urges to defecate
inadequate intake of liquid
constant physical activity
Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly?
hard, formed
black, tarry
soft, watery
dry, odorous
What are two essential techniques when collecting a stool specimen?
hand hygiene and wearing gloves
following policies and selecting containers
wearing goggles and an isolation gown
using a no-touch method and toilet paper
The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?
prone
supine
semi-fowler's
sims
The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma?
use water only
use alcohol-based sanitizer
use water and mild soap
use mineral oil
A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume?
chicken
egg yolks
brown rice
chocolate
The nurse is caring for an older adult client with diarrhea. Which finding is most important for the nurse to report to the health care provider?
Temperature of 99°F (37.2°C)
Poor skin turgor response of 6 seconds
Blood pressure of 120/70 mm Hg
Heart rate of 88 beats/min
The nurse is creating a plan of care for an older adult client at risk for constipation. Which intervention by the nurse will decrease this risk?
Advise decreasing dietary fiber in the diet to enhance stooling.
Advise increasing milk or milk products in the diet to provide stool bulk.
Encourage physical activity to improve bowel regularity.
Suggest use of warm compresses on the abdomen to increase gastrointestinal motility.
The nurse cares for a client with a chronic neurologic condition that decreases the peristalsis. What nursing diagnosis is the most likely risk for this client?
constipation
diarrhea
deficient fluid volume
excessive fluid volume
Which client is most likely to require interventions in order to maintain regular bowel patterns?
a client whose neuropathic pain requires multiple doses of opioids each day
a client with hypertension who takes a diuretic and adrenergic blocker each morning
a client who has a history of atrial fibrillation requiring daily anticoagulants
a woman 59 years of age who has recently begun hormone replacement therapy
A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?
left side-lying
prone
right side-lying
supine
An older adult resident of a long-term care home has been experiencing diarrhea for the past two days as a result of an influenza outbreak at the facility. The nurse at the care home should be aware that older adults who experience diarrhea are at increased risk of what health problem?
electrolyte imbalances
anal fissures
small bowel obstruction
peripheral and pulmonary edema
A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct?
"I will administer up to three enemas as prescribed."
"I will administer enemas until the enema return is without stool."
"You will need to have enemas unless you can consume clear liquids without nausea."
“This enema will assist in your bowel regimen when you go home.”
The normal pH range for blood is:
7.0- 7.25
7.35- 7.45
7.30- 7.40
7.00- 8.00
The kidneys compensate for acid-base imbalances by excreting or retaining:
hydrogen ions
carbonic acid
sodium bicarbonate
water
You are reviewing the results of an ABG. When the pH and the paCO2 values are moving in opposite directions, the primary problem is:
Respiratory
Renal
Metabolic
Compensation
Lab values: 7.25, paCO2 55, HCO3 45
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
metabolic alkalosis
Which acid / base imbalance do the following ABG's indicate?
pH - 7.49
pCO2 - 29
HCO3 - 23
paO2 - 78
Respiratory Alkalosis
Respiratory Acidosis
Metabolic Acidosis
Metabolic Alkalosis
When caring for a patient with chronic heart failure and chronic kidney failure, you receive the following lab results:
Na+ = 131
K+ = 6.2
Creatinine = 2.89
BUN = 66
What nursing action will the nurse take first?
Start IV isotonic fluids.
Increase Na+ in diet order.
Begin monitoring of cardiac rhythm.
Teach about the need for dialysis.
The nurse is caring for a patient with metabolic acidosis related to recent uncontrolled loose stools. Which of the following interventions will the nurse carry out first?
Give the patient an antiemetic.
Schedule the patient for dialysis.
Check patients fluid balance and electrolytes.
Investigate the patient's usual dietary plan.
The nurse caring for a patient with heart failure receives an oral report of a critical potassium level of 6.3 on the patient. What actions will the nurse take? Select all that apply.
Prepare the patient to receive IV potassium.
Place the patient on cardiac rhythm monitoring.
Check the patient's kidney function.
Place the patient on bleeding precautions.
Hold the scheduled dose of furosemide.
The nurse suspects a patient is suffering from hypermagnemesia. What assessment finding supports this suspicion?
2+ peripheral edema
hyperactive deep tendon reflexes
ventricular tachycardia
confusion and lethargy
All are causes of metabolic acidosis except:
Renal failure
Diarrhea
Hypokalemia
Diuretics
Is HCO3 an acid or a base?
Acid
Base
Is CO2 an acid or a base?
Acid
Base
Analyze the ABG: pH 7.24, pCO2 63, HCO3 24
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
ABG Analysis: pH 7.22, pCO2 37, HCO3 14
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
_______ data is observable and measurable data that can be seen, heard, felt or measured by someone other than the person experiencing them
Objective
Subjective
The act of confirming or verifying data is__________
Interview
Inference
Validation
The four methods used to collect data during an assessment (select all that apply)
Inspection
Palpitation
Percussion
Clarify
Auscultation
The _____ step of the nursing process interprets and analyzes data gathered
Assessment
Diagnosis
Implementation
Evaluation
The formulation of nursing diagnosis statements include
(select all that apply)
Problem
Defining characteristics
Related factors
Medical diagnosis
Etiology
Caring for a patient who presents with labored respirations, productive cough, and fever. What would be an appropriate nursing diagnosis for this patient? (select all that apply)
Bronchial pneumonia
Impaired gas exchange
Ineffective airway clearance
Potential complications: sepsis
Risk for septic shock
What is the nursing process?
A systematic approach used by nurses to provide care consisting of five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation.
A method for nurses to evaluate patient satisfaction after treatment.
A technique for nurses to administer medication safely and effectively.
A framework for nurses to conduct research and publish findings.
Define 'nursing diagnosis'.
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.
A nursing diagnosis is a medical term used to describe a patient's physical condition.
A nursing diagnosis is a process of evaluating the effectiveness of treatment plans.
A nursing diagnosis is a type of medication prescribed to patients.
What is the primary nursing diagnosis for a postoperative client with a new colostomy?
Impaired bowel elimination.
Risk for infection.
Acute pain.
Imbalanced nutrition: less than body requirements.
What is the significance of the planning phase in the nursing process?
The planning phase involves setting measurable and achievable short- and long-term goals for the patient.
The planning phase is primarily focused on assessing the patient's current health status.
The planning phase is where the nurse provides direct patient care and interventions.
The planning phase is mainly concerned with documenting the patient's medical history.
What action demonstrates evaluation in the nursing process after repositioning a client with difficulty breathing?
Checking the client's respiratory status.
Administering oxygen therapy immediately.
Documenting the client's repositioning in the chart.
Asking the client if they feel comfortable.
What is the purpose of the assessment phase in the nursing process?
To gather comprehensive data about the patient's health status.
To develop a treatment plan for the patient.
To evaluate the effectiveness of the treatment provided.
To educate the patient about their condition.
What are universal precautions?
safety standards of universal studios
standard requirements of PPE
universe protection from aliens
washing blood and other bodily fluids off your hands or face
What is a "normal" blood pressure
120/110 mmHg
120/80 mmHg
100/80 mmHg
140/80 mmHg
Highest pressure against blood vessels. Represented by first heat sound
diastolic pressure
systolic pressure
hypotension
hyperstension
lowest pressure against the blood vessels of the body. Measures between contractions
diastolic pressure
systolic pressure
hypotension
hypertension
A fast pulse is also called...
tachycardia
tachypnea
bradycardia
bradypnea
Normal respirations are .....
12-20 per minute
10-25 per minute
11-22 per minute
5-30 per minute
Which of the following is the normal range for pulse?
60-100
80-100
12-20
60-80
What is the normal range for SpO2?
90%-100%
100%-110%
95%-100%
80%-100%
When listening to a patient's heart sounds, which sound would mostly be heard using the diaphragm of the stethoscope? Choose those that apply
S1
S2
S3
murmur
You are caring for a patient who just arrived at the emergency department after falling down multiple times. Upon INITIAL assessment, the patient states, "I am so dizzy I can't stay standing up." What is your FIRST priority?
EKG
Vital Signs
Full neurological exam
Draw blood
When performing a head to toe assessment, we usually begin with the neurological system. What is next?
Chest, back, arm, abdomen
Hair, head, and neck, including eyes, ears, nose, and mouth
Perineal area, legs, and feet
Eyes and ears alone
A patient has just been admitted. During the physical assessment, it was observed that patient had decreased skin turgor and dried outer lips. What would be the most appropriate thing to offer this patient while the physical assessment is going on?
water
chair to sit
medications
some snacks
Which of the following are included in the neurologic assessment? Select all that apply
Cap refill
Range of motion
Level of consciousness
Pupillary response
In which order should the abdomen be assessed?
Inspect, palpate, percuss, auscultate
Auscultate, palpate, percuss, inspect
Palpate, inspect, auscultate, percuss
Inspect, auscultate, percuss, palpate
What is the purpose of auscultating the abdomen before palpation and percussion?
To get a baseline of bowel sounds
To prevent alteration of bowel sounds
To assess for any masses or lesions
To check for tenderness or pain
What information can be collected by observing the patient during a head-to-toe assessment?
Emotional status, skin color, hygiene
Vital signs, pain rating, height and weight
Cranial nerve function, respiratory rate, BMI
Blood pressure, skin breakdown, posture
What should be assessed during the inspection of the head?
Skin color, facial symmetry, abnormal movements
Hair condition, beard abnormalities, skin breakdown
Temporal artery pulsations, cranial nerve 7 function, facial expressions
Hygiene, posture, abnormal smell
What is the normal size range for pupils?
1-3 millimeters
3-5 millimeters
5-7 millimeters
7-9 millimeters
How should the tympanic membrane be inspected?
Pull the pinna down and back
Pull the pinna up and forward
Use an otoscope to visualize the membrane
Palpate for any tenderness or masses
What should be assessed during the inspection of the chest?
Respiratory rate, skin color, abnormal movements
Hygiene, posture, abnormal smell
Heart sounds, lung sounds, chest symmetry
Hair condition, beard abnormalities, skin breakdown
What is the purpose of palpating the carotid arteries during a physical examination?
To assess for any masses or lesions
To check for tenderness or pain
To evaluate the rhythm and strength of the pulse
To test cranial nerve 5 function
When does a nurse perform a physical assessment? Select all that apply
When the patient condition changes
On admission
When the nurse prescribes new medication to the patient
When evaluating the effectiveness of nursing care
Whenever things do not feel right
PERRLA stands for:
Pupils are equal, round, and reactive to light and convergence
Pupils are equal, round, and reactive to light and accommodation
Pupils are equal, round, and reactive to light according to the assessment
Pupils are equal, rough, and round to light and accommodation
