Multi choice exam Flashcards
Which of the following is incorrect about pain in the older adult?
Opioids are often the drug of choice.
Older patients may have more than one source of pain.
There is a greater likelihood of having developed a pathological condition accompanied by pain.
Elderly people who are confused or cognitively impaired do not experience pain.
Elderly people who are confused or cognitively impaired do not experience pain.
For which patient condition would you most likely expect a capillary refill time longer than two seconds? Malignant melanoma. Inflammatory bowel disease. Peripheral vascular disease. Multiple sclerosis.
Peripheral Vascular Disease
Where is the correct location to auscultate the apical pulse?
Fourth intercostal space, left midclavicular line.
Second intercostal space, right midclavicular line.
Third intercostal space, mid axilla.
Fifth intercostal space, left midclavicular line.
Fifth intercostal space, left midclavicular line.
Which of the following would be the most appropriate for you as the student nurse to do next, after a patient LOC?
Leave the patient to go and talk to the other residents about what happened.
Perform a Glasgow Coma Score.
Refer the patient for immediate follow-up.
Ask if the patient has ever had a seizure.
Perform a Glasgow Coma Score.
When performing a physical examination, which of the following would be most appropriate?
Allow the patient to remain dressed.
Omit intrusive parts of the exam.
Dim the room light.
Try to minimize position changes for the patient.
Try to minimize position changes for the patient.
Which test would be most appropriate to perform when assessing the patient eye muscle strength and cranial nerve function? Visual fields test. Cover test. Corneal light reflex test. Extra ocular movement test.
Extra ocular movement test.
Which of the following nursing assessments will give you objective data relating to the functioning of the patient's cerebellum? Vital signs. Coordination. Glasgow Coma Score Cardiac function.
Coordination.
The registered nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the patient do?
Lock the fingers together and pull against each other.
Stretch the arms over head.
Squeeze a thigh with the opposite hand.
Clench the jaw tightly.
Lock the fingers together and pull against each other.
The patient's patellar reflex is normal. Which of the following is the correct number to document this? 2+. 3+. 4+. 5+.
2+.
Which of the following would be the most likely sign of a frontal lobe contusion? Inability to hear high‐pitched sounds. Difficulty speaking. Blurred vision. Loss of tactile sensation.
Difficulty speaking.
Which of the following represents the break in sounds between the first and second sounds when auscultating blood pressure? Diastolic value. Korotkoff sounds. Auscultatory gap. Phase V.
Auscultatory gap.
You are having difficulty auscultating heart sounds, specifically S1 and S2. Which of the following would help?
Use the bell of the stethoscope to help distinguish the sounds.
Palpate the apical impulse.
Palpate the carotid pulse while auscultating the heart.
Determine the pulse deficit.
Palpate the carotid pulse while auscultating the heart.
Which type of pain would be associated with arthritis? Somatic. Chronic. Visceral. Cutaneous.
Chronic
Which of the following would lead you to suspect that the patient is experiencing pain? Regular, unlaboured breathing. Alert, talkative demeanor. Facial grimacing, leaning forward. Sitting upright, hands on lap.
Facial grimacing, leaning forward
When assessing the patient which part of the body would you assess for the presence of central cyanosis? Oral mucosa. Palms. Sclera. Nail beds.
Oral mucosa.
Which of the following processes is not required for effective respiration to occur? Ventilation. Obstruction. Perfusion. Diffusion.
Obstruction.
Which of the following is a warning sign of acute respiratory distress?
A blue tinge to the mouth and lips.
A respiratory rate of 14 breaths per minute.
The patient telling you in long sentences that they are short of breath.
An oxygen saturation recording of 93% while the patient is breathing normal room air.
A blue tinge to the mouth and lips.
Which of the following would be most important for you to remember when auscultating the patient’s posterior chest?
Listen at each site for at least one complete respiratory cycle.
Have the patient breathe deep and fast through the mouth.
Be alert to the patient’s comfort and offer rest periods.
Auscultate the base at the level of the sixth rib.
Be alert to the patient’s comfort and offer rest periods.
When auscultating the apices of the patient's lungs, where would you place your stethoscope? At the level of the diaphragm. Near the level of the eighth rib. Slightly above the clavicle. At about the tenth rib.
Slightly above the clavicle.
Which of the following describes a wheeze?
Loud bubbly sounds heard during inspiration.
High‐pitched, musical sounds heard primarily during expiration.
Damp sounds, not cleared by coughing.
High‐pitched fine, short crackling noises heard during the end of expiration.
High‐pitched, musical sounds heard primarily during expiration.
Which of the following signs is not associated with increased work of breathing?
Accessory muscle use.
Anxiety, agitation, confusion.
Clammy skin.
Respiratory rate of 12 breaths per minute.
Respiratory rate of 12 breaths per minute.
When performing a comprehensive assessment, which part of the body would you assess for information about the motor function of cranial nerve VII? Ears. Mental status examination. Mouth and throat. Head and face.
Head and face.
You are preparing to assess the patient’s distance visual acuity. Given that they wear reading glasses which of the following would be most appropriate?
Use the E chart rather than the Snellen chart for testing.
Have the patient keep the glasses on but occlude one eye.
Ask the patient to remove their glasses before testing.
Test the patient’s near visual acuity instead.
Ask the patient to remove their glasses before testing.
During the patient's ocular exam, you shine a light into one eye and the pupil of the other eye constricts. What of the following do you interpret this as? Direct reflex. Consensual response. Accommodation. Optic chiasm.
Consensual response.
Which of the following questions will help you evaluate the patient for a hearing impairment?
“Do you have a problem hearing the telephone?”
“Do people complain that you turn the TV volume up too high?”
“Do you misunderstand what others are saying and respond inappropriately?”
“Do many people you talk to seem to mumble?”
All of the above.
All of the above.
If a patient has difficulty hearing high‐pitched sounds, which of the following would you document this finding as? Otalgia. Presbycusis. Vertigo. Tinnitus.
Presbycusis.
As part of a presentation you explain how visual perception occurs. Which of the following would you include in the explanation?
Refers to what a person sees with one eye.
Allows the eyes to focus on near objects.
Involves light rays striking the retina.
Acts as a protective reflex to limit light.
Involves light rays striking the retina.
The patient asks you why cerumen is important because it “just clogs up the ear anyway”. Which response would be most appropriate?
“It helps create the smoothness of the external auditory canal.”
“It helps create the translucent, pearly colour of the eardrum.”
“It helps keep the tympanic membrane soft.”
“It helps conduct sound waves through the inner ear.”
“It helps keep the tympanic membrane soft.”
Nurses should be aware of the verbal and non‐verbal ways patients communicate discomfort. What would be an appropriate assessment tool to use with the patient? PQRSTU. A faces pain scale. A verbal descriptor scale. A numeric rating scale.
A faces pain scale.
How would you advise the patient as to the best way to reduce the risk of spreading the disease? Hand hygiene. The use of disposable gloves. The use of isolation precautions. Sterilization of equipment.
Hand hygiene.
Which of the following would be the most accurate nursing diagnosis for the patient?
The patient would like the day off school and has stuck toothpaste in her eye.
Pain related to exudate in left eye.
Potential visual impairment due to blood shot right eye.
Conjunctivitis related to itchy eye with pus.
Pain related to exudate in left eye.
