Assessment

The nurse is caring for a 50-year-old male patient with hyperthyroidism. Which assessment does the nurse anticipate?

The nurse is providing medication teaching to a patient receiving lithium for management of bipolar disorder. The nurse instructs the patient to take in similar levels of which nutrient each day?

The nurse assesses which body part to detect jaundice in the patient with dark skin?

Which tool does the nurse use to assess pain in the 4-year-old patient who sustained minor injuries on the playground? 

The nurse is caring for a 60-year-old female patient who is confined to bed and most closely monitors for signs of which complication?

The patient presents to the emergency department complaining of severe headache and muscle and joint pain that started two days ago. Vital signs are significant for a heart rate of 112 bpm and temperature of 103°F. Upon assessment, the nurse notes a maculopapular rash on the patient’s wrists. Which question is most helpful in determining the cause of this patient’s symptoms?

The patient presents with diffuse maculopapular rash, fever, myalgia, arthralgia and headache. The patient reports several tick bites after hiking two weeks ago, which prompts the provider to suspect Rocky Mountain spotted fever (RMSF). Which test confirms the diagnosis?

The patient presents to the emergency department following an incident in which he sustained burns to his hands and forearms. The patient responds, “I don’t understand what everyone is concerned about – it doesn’t even hurt that bad.” Upon assessment, the nurse notes the entirety of the dermis has been destroyed and the wound base appears beefy red. The nurse anticipates the patient will be diagnosed with which type of burn?

The nurse asks a patient to provide a urine sample for a urine culture. When the nurse returns 3 hours later, the patient says the urine sample has been sitting by the bed for the last 2 hours. Which action by the nurse is appropriate?

The patient presents to the emergency department and states, "I don't remember being bitten, but it looks like I have a spider bite on my foot." Upon assessment, the nurse notes cellulitis and a large boil that is subsequently lanced and drained. The nurse anticipates administering which antibiotic?

The patient who resides in a long term care facility is admitted to the hospital for an acute decrease in level of consciousness, confusion, and dehydration due to anorexia. The patient’s arterial blood gas, temperature, heart rate, respiratory rate, breath sounds, and bowel sounds are all within normal limits. The nurse anticipates which diagnosis?

The patient with pneumonia who has been taking PO azithromycin for four days contacts the clinic to report itching and burning in her vagina. Which response by the nurse is most appropriate?

A patient presents to the dermatology office with complaints of several areas of pruritic silver-gray patches on the elbows, knees, and trunk. The nurse anticipates which diagnosis will be made?

The 3-year-old patient is diagnosed with atopic dermatitis. The nurse provides information to the parents about which condition(s) the patient is likely to experience as he ages? Select all that apply. 

Which assessment indicates the patient with chronic pain is meditating effectively?

The nurse is instructed to assess the patient’s postvoid urine residual volume. Which is the best method by the nurse to perform this task?

The 24-year-old G1P0 female at 32 weeks estimated gestational age presents to the labor and delivery unit with recent onset of contractions and rupture of membranes. Which finding, if present in this patient, most definitively indicates the patient has entered the second stage of labor?

The nurse is caring for a G3P0 female at 40 weeks estimated gestational age in the second stage of labor. The patient does not have an epidural in place. After how many hours does the nurse contact the provider to report a prolonged second stage of labor?

A 31-year-old G2P1 female at 37 weeks estimated gestational age presents reporting contractions. Which question by the nurse would best determine if the patient is in labor?

The 25-year-old G1P0 female at 31 weeks estimated gestational age presents to the labor and delivery unit. The nurse assesses the patient and palpates the head of the fetus to be 2 inches above the maternal ischial spines. Which term does the nurse use to document this finding?

The nurse is performing a psychosocial assessment on an 84-year-old male in a hospice. The patient says, “I have had a good life. My children are grown and successful, and I was a successful businessman.” How does the nurse document this patient’s psychosocial development?

The nurse is assigned to care for a 65-year-old male patient who is diagnosed with atrial fibrillation. The nurse realizes during the shift report that six hours ago she administered 0.6 mg of this patient’s antiarrhythmic medication instead of 6.0 mg. Which action does the nurse perform first?

The nurse most closely assesses for which condition in the patient taking doxazosin? 

The nurse anticipates seeing the effect of which medication most quickly? 

A 14-year-old patient presents to the clinic complaining of right outer ear pain. Which characteristic most likely explains the cause of the pain?

Upon arrival of the patient to the post-anesthesia recovery unit (PACU), which assessment does the nurse perform first?

The patient reports being hungry prior to the breakfast tray delivery. When the nurse checks on the patient an hour after the tray was delivered, the nurse notes the patient has not eaten any of the food. Which initial nursing action is most appropriate? 

Which assessment in the patient with bladder cancer indicates the patient is experiencing a complication of the disease?

Which assessment prompts the nurse to suspect intussusception in the 10-month-old patient? 

Which finding is expected in the patient with diabetic ketoacidosis (DKA)?

The patient presents to the emergency department with chest pain. Which description of the pain prompts the nurse to suspect a myocardial infarction?

Which patient must be treated first in the emergency department following a mass shooting?

Which assessment at the beginning of the shift of the patient with a recent head injury requires the most immediate action?

The patient is rushed into the emergency department by a family member who states the patient is having a stroke. Which action does the nurse take first?

The nurse is providing education to a patient with localized shingles. Which statement by the patient indicates the teaching was effective?

The nurse holds the transfusion and contacts the blood bank if which anemic patient is sent B negative packed red blood cells for transfusion?

The 8-year-old presents with a generalized rash. The patient's mother reports that some areas of the rash have developed into pimples that are oozing clear fluid. The nurse places this patient on which type of precaution(s)? Select all that apply.

The patient with antisocial personality disorder is known to have violent outbursts. Which actions by the patient indicate the patient may become physically violent? Select all that apply.

A first-time mother brings in her one-year-old daughter for a check-up. Which assessment finding requires further investigation?

Which statement by a patient with type 1 diabetes mellitus indicates understanding of teaching about the recommended diet?

Which statement by a patient recently diagnosed with congestive heart failure indicates an understanding of the teaching provided by the nurse?

The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?

The patient presents with acute confusion after she was found outside by the police, and it appears she has taken some kind of illegal substance. She is unable to answer any questions. Which finding most indicates abuse?

The patient with acute psychosis tells the nurse he is going to leave this earth soon and go live in a house with the little green men on Mars. Which is the best response to this statement?

Which signs indicate that a patient with chronic depression may be planning to commit suicide? Select all that apply.

The nurse receives report on a 76-year-old patient who is recovering from surgery for creation of an ileal pouch-anal anastomosis. The nurse plans care to prevent which complication that is most specific to this patient?

The patient’s thyroid stimulating hormone (TSH) is 9.3 mIU/L and serum free thyroxine (T4) is 0.2 ng/dL. Which findings are consistent with these lab results? Select all that apply.

The patient complains of cold intolerance, weight gain, and hair loss. The nurse notes periorbital and generalized, non-pitting edema. The patient’s blood pressure is 98/64 mmHg and heart rate is 48 bpm. The nurse anticipates which lab result?

The 6-month-old infant is admitted to the pediatric intensive care unit with a diffuse purpuric rash and prolonged bleeding. The nurse notes the fingers on the right hand are pale and cool to the touch. Which question asked of the parents will be the most helpful in diagnosing this patient’s condition?

The urine output of a 40-year-old male patient with a urethral catheter has decreased from 80 mL/h to 15 mL/h. Which action should the nurse take first?