Assessment

The patient with chronic pain and generalized anxiety disorder has been prescribed alprazolam. Which medication, if also prescribed to the patient, prompts the nurse to clarify the order with the provider?

Which developmental milestone is expected of the six-month-old infant who presents for a routine check-up?

At a well-child visit, the mother of a 2-year-old child states, "My child is not keeping up with the other kids." Further evaluation reveals the patient can stack 6 cubes, walk backwards, and copy a line. The child exhibits separation anxiety and has a vocabulary of 10 words but cannot use symbols or use pronouns. Which assessment does the nurse make about the child's development?

The nurse informs the parent of an 18-month-old patient at the well-child visit that screening for an autism spectrum disorder at which time(s)?

The nurse receives report on a 24-year-old G1P0 female at 32 weeks estimated gestational age who presents with pre-eclampsia with severe features. The nurse expects the patient to exhibit which symptom? 

The older adult patient is brought to the emergency department with sudden onset confusion, agitation, and hallucinations. The patient's past medical history is significant for type 2 diabetes managed with glyburide, anxiety managed with lorazepam, and insomnia managed with zolpidem. Upon assessment, the patient's heart rate and rhythm are regular, lungs are clear to auscultation, and bowel sounds are present. Vital signs are normal, with exception of a slightly elevated heart rate. Which is the most likely cause of the patient's symptoms?

Which assessment is most consistent with disorganized schizophrenia? 

The patient brought to the emergency department by police was found in the middle of traffic, alternating between grandiose declarations and expressing a desire to commit suicide. On physical assessment, the patient is tachycardic and hypertensive. The nurse suspects which diagnosis will be made?

The unresponsive patient is brought via ambulance to the emergency department.  On physical assessment, the patient has a respiratory rate of 8 breaths per minute and pinpoint pupils. The nurse suspects which cause of the patient's condition?

A confused, minimally arousable patient is brought to the emergency department via ambulance. The patient is hypotensive and bradypneic. Paramedics report finding an empty bottle of diazepam next to the patient. The nurse prepares which therapy?

Which condition qualifies the patient to be an emancipated minor?

Which generation is known for being team-oriented, hardworking, efficient multi-taskers, and respectful of authority?

The nurse notes inspiratory stridor upon auscultating the breath sounds of a 2-year-old child and suspects obstruction at which structure?

Following a motor vehicle accident, the patient is noted to have an estimated blood loss of 500 mL and the blood pressure is normal. The nurse anticipates the provider to diagnose the patient with which class of shock?

The 85-year-old patient fell in the bathroom. Which score will most accurately predict the adverse effects the patient will experience from the fall?

The patient has a peripherally inserted central catheter (PICC) for the long-term administration of parenteral nutrition, oxacillin, and gentamicin. Which assessment findings, if present in the patient, indicate the patient is experiencing a complication of the PICC line? Select all that apply.

The patient presents to the emergency room complaining that his heart is racing and he feels dizzy. His heart rate is 220 bpm, his blood pressure is 80/40 mmHg, and his capillary refill is 5 seconds. He is diaphoretic and is becoming increasingly lethargic. The nurse anticipates which order first?

The nurse is providing discharge teaching to the patient who has experienced episodes of atrioventricular nodal reentry tachycardia (AVNRT). Which patient drink selection(s), if chosen by the patient, indicate a need for further teaching? Select all that apply.

The patient in the intensive care unit who is intubated and mechanically ventilated abruptly requires a drastically increased fraction of inspired oxygen (FiO2) and is hypoxic, hypotensive, and tachycardic. Which intervention does the nurse perform first?

The family practice nurse is reviewing telephone messages from patients. Which call is to be returned first?

The nurse receives shift report on four patients. In which order does the nurse see the patients? Place the answer options in the correct order.

Which statement by a patient in the obstetrician's clinic is most concerning?

The nurse is planning care for the patient with severe liver disease who has substantial ascites and peripheral edema. Which interventions are included in the care plan? 

The patient is brought to the emergency department after a motorcycle accident which resulted in head trauma. The nurse observes a hematoma and bruising around the mastoid bone. Which term does the nurse use to document the finding?

The nurse receives report on the patient experiencing thyroid storm. Which symptom does the nurse expect to observe?

The home health nurse is working with a patient who is a fall risk. During a home visit, the nurse sees the patient repeatedly using a step stool. Which intervention is the most appropriate?

A missed menstrual period is which type of sign of pregnancy?

The nurse is performing an assessment of an infant born 8 hours ago. The infant’s POC blood glucose level is 25 mg/dL. Which action does the nurse take first?

The nurse is assessing the elderly patient in the long-term care facility. Which findings suggest urinary catheter-associated urinary tract infection (CAUTI)? Select all that apply.

The nurse is performing an initial assessment on a 26-year-old patient. The nurse auscultates a high-pitched sound late in systole, like a click. This sound most likely indicates which condition?

The patient is hunched over in the emergency department waiting room, breathing slowly and shallowly. His wife insists he “took something”. The man has bradypnea and marked miosis. Which intoxicant does the nurse suspect?

Which patient is triaged first in the emergency department? 

The gravida 1 para 1 woman delivered an infant at 41 weeks gestation that weighed 9 lbs. 2 oz. She received oxytocin during labor and forceps were used to assist in the delivery. The nurse is most concerned for which complication?

The patient with angina is experiencing crushing chest pain but the ECG shows no abnormalities. Which lab result indicates the patient is experiencing a non-ST segment elevation myocardial infarction (NSTEMI)? 

The day after administering a blood product to the anemic patient, the nurse learns it was contaminated with a fungal pathogen due to improper processing. The nurse is vigilant for which symptom(s)?

Which type of bowel sounds does the nurse expect to hear when auscultating the abdomen of a patient with watery diarrhea?

The patient presents to the emergency room (ER) after having a fever for three days and new onset severe chest pain behind the sternum. The patient asks, “What is wrong with me? Do I have pneumonia? It hurts when I breathe.” Upon assessment, the nurse notes a heart rate of 124 bpm, temperature of 37.9°C, and an intermittent friction rub upon auscultation. The lungs are clear. The nurse suspects further testing will lead to a diagnosis of which condition?

The nurse assists with a pericardiocentesis to drain a pericardial effusion and notes serosanguinous fluid. The nurse suspects which condition?

The patient presents to the emergency department (ED) with nausea, vomiting, fever, severe knee and wrist pain, nosebleed, and lymphadenopathy. A new murmur is noted, as well. The nurse asks the patient about a recent history of which infection?

Which neurologic alteration is associated with acute rheumatic fever?

Which urinalysis findings support the diagnosis of shock in the hypotensive patient? Select all that apply.

The child suffered a radial fracture that has just been immobilized with a plaster cast. Which action by the nurse is appropriate? 

There are four patients with hyperglycemia in the emergency department triage. One treatment room has become available. The patient with which additional symptom is moved into the available room first?

Prior to initiating routine hemodialysis for the patient with end stage renal disease (ESRD), which assessments does the nurse perform? Select all that apply.

The patient wants to quit smoking before starting hormonal birth control. Using motivational interviewing, which statement by the nurse would best elicit change talk from the patient?

The nurse provides which instruction to the patient who will undergo guaiac stool testing?

The nurse assesses the cuff pressure of the patient's tracheostomy. Which cuff pressure prompts the nurse to document the finding and proceed with the assessment?

Which symptoms, if present in the patient receiving a blood transfusion, indicate the patient is experiencing an acute hemolytic transfusion reaction? Select all that apply.

The nurse is preparing for the well-baby visit for a 4-month-old baby and expects which behaviors from the patient? Select all that apply.

The nurse is planning care for the patient receiving adalimumab. Which nursing intervention does the nurse utilize to prevent complications of the medication?