Assessment

During the initial home visit, the home health nurse assesses which of the elderly patient's basic activities of daily living? Select all that apply.

Body mass index (BMI) is calculated using which measurement(s)?

The patient suddenly begins slurring. The nurse assesses the patient for additional symptoms of which condition?

The patient's serum calcium quickly changed to 14 mg/dL (3.5 mmol/L). The nurse anticipates observing which symptoms? Select all that apply.

The patient presents to the emergency department (ED) with flu-like symptoms and mucocutaneous erythematous rash and bullae formation over 38% of the body. The nurse asks the patient if which medications had been taken in the last month? Select all that apply.

The nurse assesses the patient for which signs of complications of a parathyroidectomy?

The 7-month-old infant is sitting quietly on the mother’s lap. Which assessment does the nurse perform first?

Which is indicated by a positive urea breath test?

Which respiratory assessment in the patient who has an oxygen saturation of 96% on room air is most concerning?

Which fundal height is documented as normal for the woman who is 30 weeks pregnant?

Which term does the nurse use to document a 1.5 cm, dark red, fluid-filled lesion on the patient's cheek?

Which term does the nurse use to document the pinpoint, non-blanchable rash in the child who has invasive meningococcal disease (IMD) caused by Neisseria meningitidis? 

The patient with vasculitis has a rash of red marks that are greater than 3 mm and do not blanch when pressed. Which term does the nurse use to document this finding? 

The patient presents to the emergency department with left leg pain after landing from a transcontinental flight. Which assessments prompt the nurse to suspect a deep vein thrombosis? Select all that apply.

Following an infection with rhinovirus, the patient reports initial improvement followed by significant congestion and upper teeth pain. The nurse anticipates which diagnosis?

The patient has been diagnosed with ethmoid sinusitis. The nurse anticipates the patient to complain of tenderness upon percussion of which area?

The patient presents to the emergency department (ED) with green sputum and severe pain over the top teeth, cheeks, and forehead following a respiratory viral infection. The provider requests the nurse use the transilluminator to assess for sinusitis. Which assessment indicates maxillary sinusitis?

The nurse assesses the patient with acute ethmoid sinusitis for which symptom that indicates the patient is experiencing a severe complication of the condition?

The nurse is performing an assessment on the patient with long, thin limbs and fingers who presents for a yearly check-up in no acute distress. The patient is extremely thin and has pectus excavatum. For which assessment finding is the nurse most vigilant in this patient?

The patient has a history of mitral valve stenosis. In which position does the nurse place the patient to properly auscultate for this condition?

Which cardiac enzyme is indicated by the dotted line ( ) on the chart?

Which cardiac enzyme is represented by the dot/dash alternating () line?

Which cardiac enzyme is indicated by the dashed ( ) line?

Which cardiac enzyme is noted by the solid line ( )?

The nurse auscultates an opening snap after the second heart sound when the stethoscope is placed to the left of the lower sternum. Which additional heart sound does the nurse expect to hear?

The nurse is reviewing the admission assessment of a new patient and notes a IV/VI murmur was heard during auscultation of the heart. The nurse anticipates making which assessment?

The patient presents to the emergency department (ED) after a hard workout lifting weights complaining of chest pain. An electrocardiogram is performed and cardiac enzymes are drawn. The patient’s myoglobin level is found to be elevated. Which interpretation of this result is most appropriate?

Which phonocardiogram tracing indicates a common heart condition associated with prematurity?

The patient is scheduled for an aortic valvuloplasty. The nurse anticipates auscultation of the heart will reveal which pattern?

The patient with Marfan syndrome presents with difficulty breathing in the supine position and fatigue. Upon palpation, a heave is noted. The nurse anticipates auscultating which heart sound?

The nurse notes these heart sounds on auscultation of a 65-year-old man: The nurse reviews the patient’s medical record for history of which conditions associated with these heart sounds? Select all that apply.

During a well-child visit for the 4-month-old child, the nurse palpates hard nodules where each rib joins the sternum. The nurse reports this finding to the provider and requests which lab studies for this patient? Select all that apply.

The nurse is assessing the arteriovenous fistula in the patient’s right arm; it is without thrill or bruit. Which action does the nurse take next?

Following abdominal surgery, the patient remains intubated in the postanesthesia care unit (PACU). Which assessment indicates the patient is ready to be extubated?

The woman who is 36-weeks pregnant reports sudden and severe abdominal pain. Which assessment does the nurse perform first?

The 76-year-old patient with atrial fibrillation tells the nurse in a slurred voice that the right arm “just isn’t working right.” Which action does the nurse take first?

Which breath sound is the most concerning after endotracheal extubation?

The patient with a brain neoplasm reports experiencing visual misperceptions. The nurse suspects the brain tumor is in which lobe of the brain? 

The patient presents to the emergency department exhibiting stiff, jerky movements of the face and neck. The nurse reviews the patient's medical history for a prescription for which medication? 

The patient with an automated implantable cardioverter-defibrillator (AICD) experiences a discharge of the device. The nurse reports this event to the provider with the knowledge that the patient experienced which arrhythmia?

The obstetrician performs a pelvic exam and reports that the 39-weeks-gestation woman is at 4 cm and zero station. The nurse interprets the fetus's head to be in which location? 

During assessment of the patient with an ileostomy, the nurse discovers that the opening of the pouch is about 5/8” inch larger than the stoma. This patient is at increased risk for which adverse outcome?

The patient receiving mechanical ventilation opens the eyes, attempts to talk, and appears to be in distress. Which action does the nurse take first?

Which actions does the nurse take to obtain a sample for culture from the third degree burn wound that appears to be infected? Select all that apply.

The nurse in the intensive care unit (ICU) hears repeated high pressure alarms from the mechanical ventilator of the intubated patient and suspects which condition?

The nurse in the intensive care unit (ICU) hears repeated low pressure alarms from the ventilator of the intubated patient and suspects which condition?

Which statement is true regarding the administration of intravenous potassium?

The nurse is using the Finnegan scoring system to assess a neonate for opioid withdrawal. The first score is 9 and the second score is 14. Which statement is accurate?

The nurse is caring for a woman who gave birth via forceps delivery within the last 24 hours. The patient describes significant rectal pressure but has had normal bowel movements. The nurse reports the finding to the provider with concerns for which postpartum complication?

A high school wide receiver suffered substantial head trauma during a tackle. The school nurse is concerned about concussion. The nurse provides which information to the adolescent and parents? Select all that apply.