Acute Care Exam 2 with 100% correct answers 2022/2023

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The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1) Appearance and behavior 2) Meas... urement of vital signs 3) Observing specific body systems 4) Conducting a detailed health history correct answer1) Appearance and behavior Correct The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include? 1) Place the palm of the hand on the child's back. 2) Lightly touch the child's forehead with the fingertips. 3) Place the back of your hand against the child's forehead and then on the back of the neck. 4) Use the pads of your fingers and press against the child's neck and over the thorax. correct answer3) Place the back of your hand against the child's forehead and then on the back of the neck. While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider? 1) Respiratory rate: 14 2) Pain reported when palpating posterior lower thorax 3) Thorax rising and falling symmetrically for right and left lungs 4) Vesicular breath sounds heard with auscultation of peripheral lung fields correct answer2) Pain reported when palpating posterior lower thorax The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include? 1) Avoid sunbathing between 3 PM and 7 PM. 2) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun. 3) Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown. 4) Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor. correct answer2) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun. As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.) 1) Applying adhesive tape to anchor a nasogastric tube 2) Inserting a rubber Foley catheter into the patient's bladder 3) Providing oral hygiene using a standard toothbrush and toothpaste 4) Giving an injection using plastic syringes with rubbercoated plungers 5) Applying a transparent wound dressing correct answer1) Applying adhesive tape to anchor a nasogastric tube 2) Inserting a rubber Foley catheter into the patient's bladder 4) Giving an injection using plastic syringes with rubbercoated plungers The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up? 1) Palpation of a femoral pulse with a heart rate of 76 2) Auscultation of a heart murmur over the left thorax 3) Identification of mild bruising at the catheter insertion site 4) Palpation of a right dorsalis pedis pulse with strength of +1 correct answer4) Palpation of a right dorsalis pedis pulse with strength of +1 The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient's reported symptoms related to upper respiratory infection? 1) Buccal mucosa is moist and dark pink. 2) Respiratory rate is 18, rhythm is even. 3) Retropharyngeal lymph nodes are enlarged and firm. 4) Inspection with a tongue depressor on the posterior tongue causes gagging. correct answer3) Retropharyngeal lymph nodes are enlarged and firm. The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.) 1) A normal pulse on the top of the foot indicates adequate blood flow to the foot. 2) To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee 3) When there is poor arterial blood flow, the leg is generally warm to the touch. 4) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. correct answer1) A normal pulse on the top of the foot indicates adequate blood flow to the foot. 4) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? 1) Supine with both arms overhead with palms upward 2) Sitting with hands clasped just above the umbilicus 3) Supine with the right arm abducted and hand under the head and neck 4) Lying on the right side, adducting the right arm on the side of the body correct answer3) Supine with the right arm abducted and hand under the head and neck The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include? 1) The aorta can be felt using deep palpation in the upper abdomen near the midline 2) The patient should be sitting to best determine the contour and shape of the abdomen. 3) Always wear gloves when palpating the skin on the patient's abdomen. 4) Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness. correct answer1) The aorta can be felt using deep palpation in the upper abdomen near the midline The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct? 1) "The testes are normally round and feel smooth and rubbery." 2) "The best time to do a testicular self-examination is before your bath or shower." 3) "Perform a testicular self-examination weekly to detect signs of testicular cancer." 4) "Since you are over 40 years old, you are in the highest risk group for testicular cancer." correct answer1) "The testes are normally round and feel smooth and rubbery." The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding? 1) Patient was not able to flex arm at shoulder. 2) Extension of right arm is limited. 3) Patient's abduction of right arm was limited to 100 degrees. 4) Internal rotation of right arm is limited to less than 90 degrees. correct answer3) Patient's abduction of right arm was limited to 100 degrees. ID: 41140170 The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform? 1) "Tell me where you are." 2) "What can you tell me about your illness?" 3) "Repeat these numbers back to me: 7...5...8." 4) "What does this mean: 'A stitch in time saves nine? ' " correct answer4) "What does this mean: 'A stitch in time saves nine? ' " The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient? 1) VII — Facial 2) V — Trigeminal 3) XII — Hypoglossal 4) XI— Spinal accessory correct answer1) VII — Facial The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.) 1) Inspect the lips and mucous membranes to determine if they are moist. 2) Pinch the skin on the bac [Show More]

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