Nursing The Person With Althered Physical Health Bn805

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  • 1/64 Questions

    Pulse oximetry measures

    • Peripheral blood flow
    • Venous oxygen saturation
    • Central arterial flow
    • Arterial oxygen saturation
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About This Quiz

This quiz for 'Nursing the person with altered physical health BN805' assesses key competencies in respiratory assessment techniques, including understanding and identifying different lung sounds, pulse oximetry, and tactile fremitus. It is essential for nursing students and professionals aiming to enhance patient care skills.

Nursing The Person With Althered Physical Health Bn805 - Quiz

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  • 2. 

    When you are ausculating Mrs Rose's chest , you hear low-pitched, coarse sounds primarily on expiration. This best describes

    • Rhonchi (or sonorous wheezes)

    • Sibilant wheezes

    • Crackles

    • Pleural friction rub

    Correct Answer
    A. Rhonchi (or sonorous wheezes)
    Explanation
    When auscultating Mrs. Rose's chest and hearing low-pitched, coarse sounds primarily on expiration, this indicates the presence of rhonchi (or sonorous wheezes). Rhonchi are caused by airway obstruction due to mucus or other secretions, leading to a turbulent airflow and resulting in low-pitched sounds. These sounds are typically heard more prominently during expiration. Sibilant wheezes, on the other hand, are high-pitched sounds heard during both inspiration and expiration, often associated with asthma or bronchospasm. Crackles are discontinuous, non-musical sounds heard during inspiration and can indicate fluid or inflammation in the lungs. Pleural friction rub is a grating, scratchy sound caused by inflamed pleural surfaces rubbing together, typically heard during both inspiration and expiration.

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  • 3. 

    On another patient, Mr Paku you ausculate musical, squeaky sounds bilaterlly in his lung fields.  This is best described as

    • Crackles

    • Rhonchi (or sonorous wheezes)

    • Sibilant wheezes

    • Pleural friction rub

    Correct Answer
    A. Sibilant wheezes
    Explanation
    Sibilant wheezes are high-pitched, musical sounds heard during inspiration and expiration. They are typically caused by the narrowing of the airways due to inflammation or constriction. In the case of Mr. Paku, the presence of musical, squeaky sounds bilaterally in his lung fields suggests the presence of sibilant wheezes. These wheezes are commonly associated with conditions such as asthma or bronchitis.

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  • 4. 

    Your understanding of creps, rales or crackles is

    • Indicative of pneumothorax

    • Caused by consolidation, mass or atelectasis

    • Indicative of a pleral friction rub

    • Created when air is moving through smaller air passages narrowed by mucous or pus

    Correct Answer
    A. Created when air is moving through smaller air passages narrowed by mucous or pus
    Explanation
    The given correct answer states that creps, rales, or crackles are created when air is moving through smaller air passages narrowed by mucous or pus. This suggests that these abnormal lung sounds are indicative of an obstruction or blockage in the air passages, which could be caused by conditions such as bronchitis, pneumonia, or asthma. This explanation aligns with the medical understanding of creps, rales, and crackles as abnormal lung sounds that occur due to the presence of fluid or inflammation in the airways.

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  • 5. 

    Auscultation of the lungs should reveal which normal finding?

    • Vesicular breath sounds in all lung fields posteriorly

    • Bronchial breath sounds heard faintly over the apices of both lungs

    • Bronchovesicular breath sounds over the periphery of the posterior chest wall

    • No breath sounds heard at the most extreme margins of the anterior and posterior lungs

    Correct Answer
    A. Vesicular breath sounds in all lung fields posteriorly
    Explanation
    Auscultation of the lungs should reveal vesicular breath sounds in all lung fields posteriorly. Vesicular breath sounds are normal and are heard over most of the lung fields. They are characterized by a soft, low-pitched sound during inspiration and a shorter, higher-pitched sound during expiration. This is the expected finding when auscultating the lungs.

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  • 6. 

    The best technique for checking tactile fremitus is to use the ulnar surface of the hand

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The ulnar surface of the hand is the best technique for checking tactile fremitus because it is the most sensitive area for detecting vibrations in the chest. When the person being examined speaks, these vibrations can be felt through the ulnar surface, providing valuable information about the condition of the lungs and underlying tissues. This technique is commonly used by healthcare professionals to assess for abnormalities such as fluid in the lungs or consolidation.

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  • 7. 

    When percussing over normal lung fields, the sound you would expect to hear would be

    • Dull

    • Sonorous

    • Resonate

    • Crackling

    Correct Answer
    A. Resonate
    Explanation
    When percussing over normal lung fields, the sound you would expect to hear is "resonate." Resonance is the normal sound produced when percussing over healthy lung tissue. This sound indicates that the air-filled lungs are vibrating freely and producing a clear, hollow sound. Dullness, sonorousness, and crackling are not the expected sounds over normal lung fields and may indicate abnormalities such as consolidation, fluid accumulation, or lung tissue damage.

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  • 8. 

    Mr James, age 75 is admitted to the hospital with shortness of breath(SOB), a temp of 40degrees and substernal chest pain. He has a history of emphysema and a recent upper respiratory infection. You ausultate a low-pitched grating sound over his left anterior chest that persists even when he holds his breath. You suspect which of the following?

    • Tension pneumothorax

    • Pericardial friction rub

    • Plural friction rub

    • Consolidation

    Correct Answer
    A. Pericardial friction rub
    Explanation
    Based on the given information, Mr. James is presenting with symptoms such as shortness of breath, high temperature, substernal chest pain, and a history of emphysema and upper respiratory infection. The low-pitched grating sound heard over his left anterior chest that persists even when he holds his breath suggests a pericardial friction rub. A pericardial friction rub is a classic sign of pericarditis, which is inflammation of the pericardium (the sac surrounding the heart). This condition can cause chest pain and difficulty breathing, which aligns with Mr. James' symptoms.

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  • 9. 

    Possible age-related changes which may affect ventilation include

    • Loss of elastic fibres in the lungs

    • Clacification in the rub cartilage

    • Reduced ciliary activity

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    As individuals age, several changes occur in the respiratory system that can affect ventilation. The loss of elastic fibers in the lungs leads to decreased lung compliance, making it harder for the lungs to expand and contract efficiently. Calcification in the rib cartilage can restrict chest wall movement, further limiting the ability to breathe deeply. Reduced ciliary activity in the respiratory tract impairs the clearance of mucus and debris, increasing the risk of respiratory infections. Therefore, all of the given options - loss of elastic fibers in the lungs, calcification in the rib cartilage, and reduced ciliary activity - can contribute to age-related changes that affect ventilation.

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  • 10. 

    When assessing John C, aged 64, who has chronic obstructive lung disease, the nurse assesses tactile fremitus

    • When assissin tactile fremitus, ask the patient to whisper "1,2,3"

    • When assissing tactile fremius, use the soft pads of your finger tips

    • Fremius is increased in the presence of pneumothorax or chronic obstructive lung disease

    • Fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia

    Correct Answer
    A. Fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia
    Explanation
    The correct answer explains that fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia. This means that when there is consolidation in the lungs due to lobar pneumonia, the transmission of sound is enhanced, resulting in increased fremitus. This information is relevant when assessing John C, who has chronic obstructive lung disease, as it helps the nurse differentiate between the two conditions based on the tactile fremitus assessment.

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  • 11. 

    Which of the following statements regarding percussion is INCORRECT?

    • Involves tapping the body lightly as in indirect, direct or immediate percussion, or fist percussion

    • Requires the patient to say "99" or "a" during percussion

    • Assists in the detection of fluid or air in a cavity

    • Enables the determination of postion, size and density of underlying sturctures

    Correct Answer
    A. Requires the patient to say "99" or "a" during percussion
    Explanation
    Percussion is a technique used in physical examination to assess the underlying structures of the body by tapping on the body surface. It can help in detecting fluid or air in a cavity and determining the position, size, and density of underlying structures. However, it does not require the patient to say "99" or "a" during percussion. This statement is incorrect as it does not align with the actual procedure of percussion.

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  • 12. 

    The nurse notes that thoracic expansion is greater on the left side than the right and -

    • Refers the client ot a physician for additional examination

    • Documents this as a variation but within normal findings

    • Instructs the client to rest bridfly then repeats the examination again

    • Asks the client to repeat the numbers "99" while observing chest wall movements

    Correct Answer
    A. Refers the client ot a physician for additional examination
    Explanation
    The nurse refers the client to a physician for additional examination because the observation of greater thoracic expansion on the left side than the right could indicate a potential underlying issue or abnormality. It is important to have a physician assess the client to determine the cause of this asymmetry and to rule out any potential health concerns.

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  • 13. 

    You are working with a client who has respiratory disease.  You find that this client is able to breathe only in an upright or standing position.  In charting, you could describe the diffiuclty breathing in any psoition other than an upright or standing positon, or you could use the term for this condition, which is -

    • Bradynpnea

    • Tachypnea

    • Orthopnea

    • Eupnea

    Correct Answer
    A. Orthopnea
    Explanation
    Orthopnea is the term used to describe the difficulty in breathing in any position other than an upright or standing position. This condition is commonly seen in individuals with respiratory diseases. Bradypnea refers to abnormally slow breathing, tachypnea refers to abnormally rapid breathing, and eupnea refers to normal breathing.

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  • 14. 

    An appropriate nursing intervention for a patient with pneumonia with the nursing diagnoisis of ineffective airway clearance related to thick secretions would be

    • Administer oxygen as prescribed to maintain optimal oxygen levels

    • Teach the patient how to cough effrectively to bring secretions to the mouth

    • Provide analgesics ordered to promote comfort

    • Perform postural drainage every hour

    Correct Answer
    A. Teach the patient how to cough effrectively to bring secretions to the mouth
    Explanation
    Teaching the patient how to cough effectively to bring secretions to the mouth is an appropriate nursing intervention for a patient with pneumonia and ineffective airway clearance related to thick secretions. This intervention helps the patient to effectively clear their airway by coughing and expelling the thick secretions. By teaching the patient the correct technique, they can actively participate in their own care and improve their airway clearance, which can ultimately help in preventing complications and promoting recovery.

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  • 15. 

    The posterior tibial pulse may be palpated o the inner (medial) aspect of the ankle -

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The posterior tibial pulse can be felt on the inner (medial) side of the ankle. This is a true statement.

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  • 16. 

    Which of the following indicates the normal location of the apical pulse in an adult?

    • Fifth left intercostal space, medial to mid-clavicular line

    • Fourth left intercostal space, mid-clavicular line

    • Fifth intercostal space, anterior axillary line

    • Fourth intercostal space, left sternal border

    Correct Answer
    A. Fifth left intercostal space, medial to mid-clavicular line
    Explanation
    The correct answer is "fifth left intercostal space, medial to mid-clavicular line." The apical pulse is located at the fifth intercostal space, which is the space between the ribs, on the left side of the chest. It is specifically located medial to the mid-clavicular line, which is an imaginary line drawn vertically down the middle of the clavicle. This is the standard location for measuring the apical pulse in adults.

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  • 17. 

    Which of the following statements regarding cardiac landmarks and auscultation is CORRECT?

    • Erb's point is located midsternum in the epigastice area

    • Listening to heart sounds through clothing may be reliable

    • The forward sitting and left lateral decubitus postions aid in detecting murmurs

    • The mitral area is in the second left intercostal space

    Correct Answer
    A. The forward sitting and left lateral decubitus postions aid in detecting murmurs
    Explanation
    The forward sitting and left lateral decubitus positions are commonly used during cardiac auscultation to aid in detecting murmurs. In the forward sitting position, the patient leans forward to bring the heart closer to the chest wall, making it easier to hear abnormal sounds. The left lateral decubitus position involves lying on the left side, which can help accentuate certain heart sounds and murmurs. These positions allow for better detection and evaluation of murmurs, making the statement correct.

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  • 18. 

    To accurately assess the carotid pulse

    • Place two fingers of each hand firmly over the right and left temples at the same time

    • Palpate firmly with tow fingers in the inguinal space between the navel and sympysis pubis

    • Place the fingers gently in the space between the biceps and triceps muscle

    • Plapate each carotid pulse independently at the sternocleidomatoid muscle

    Correct Answer
    A. Plapate each carotid pulse independently at the sternocleidomatoid muscle
  • 19. 

    Which of the following statements accurately describes a pulse deficit

    • The apical pulse is greater than the radial pulse

    • The peripheral pulse is not palpable

    • A condition in which the arterial pulse is less than 60 bpm

    • The pulse is palpable but easy to obliterate

    Correct Answer
    A. The apical pulse is greater than the radial pulse
    Explanation
    both apical and radial pulse should be the same

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  • 20. 

    Mr Pain was admitted to coronary care with a diagnosis of myocardial infarction. 2 days follwoing Mr Pain has a temp of 37.9 degress. The nurse should

    • Encouirage deep breathing and coughing every 2 hours

    • Record the temperature and monitor vital signs at routine intervals

    • Auscultate the chest for diminished breath sounds

    • Notify the physician immediately about the tempreture

    Correct Answer
    A. Record the temperature and monitor vital signs at routine intervals
    Explanation
    The correct answer is to record the temperature and monitor vital signs at routine intervals. This is because a temperature of 37.9 degrees Celsius is slightly elevated but not significantly high. It is important to monitor the temperature and vital signs regularly to assess for any changes or worsening of the patient's condition. Encouraging deep breathing and coughing every 2 hours may be beneficial for preventing complications such as pneumonia, but it is not specifically indicated in this situation. Auscultating the chest for diminished breath sounds may be relevant in assessing respiratory function, but it is not the most appropriate action to take based solely on an elevated temperature. Notifying the physician immediately about the temperature is not necessary unless there are other concerning symptoms or signs.

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  • 21. 

    Age-related changes that may alter cardiovascular health include

    • Decrease in S-A node cells

    • Calcification in mitral or aortic valves

    • Venous distention

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    As individuals age, their cardiovascular health can be affected by several changes. Firstly, there may be a decrease in S-A node cells, which are responsible for initiating the electrical signals that regulate heart rhythm. Additionally, calcification can occur in the mitral or aortic valves, which can lead to valve dysfunction and affect blood flow. Lastly, venous distention, or the swelling of veins, can also occur with age, potentially impacting cardiovascular health. Therefore, all of the above changes can alter cardiovascular health as individuals age.

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  • 22. 

    Which perpheral pulse may be palpated at the upper surface of the foot?

    • Dorsal plantar

    • Posterior tibial

    • Femoral

    • Dorsalis Pedis

    Correct Answer
    A. Dorsalis Pedis
    Explanation
    The correct answer is Dorsalis Pedis. The Dorsalis Pedis pulse can be palpated on the upper surface of the foot. This pulse is important for assessing blood flow to the foot and is commonly checked during physical examinations.

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  • 23. 

    Cardiac murmurs
    1. may be caused by high flow rates through normal valves
    2. are generally innocent in older adults
    3. may be caused by forward flow of blood through a constricted valve or into a dilated chamber
    4. may be caused by backward flow through a defective or incompetent valve

    • 1,3,4

    • 1,2,3

    • 1,2 only

    • 3,4 only

    Correct Answer
    A. 1,3,4
    Explanation
    Cardiac murmurs can be caused by high flow rates through normal valves, forward flow of blood through a constricted valve or into a dilated chamber, and backward flow through a defective or incompetent valve. This means that options 1, 3, and 4 are correct. Option 2, which states that cardiac murmurs are generally innocent in older adults, is incorrect.

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  • 24. 

    Increases in the resting pulse rate are associated with all of the following EXCEPT

    • Infection and fever

    • Decreases in blood pressure secondary to shock

    • Sympathomimetic drugs

    • Parasympathetic nervous system stimulation

    Correct Answer
    A. Parasympathetic nervous system stimulation
    Explanation
    Increases in the resting pulse rate are associated with infection and fever, decreases in blood pressure secondary to shock, and sympathomimetic drugs. However, parasympathetic nervous system stimulation typically causes a decrease in heart rate, not an increase. Therefore, it is not associated with increases in the resting pulse rate.

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  • 25. 

    When assessing cyanosis, the nurse will utilise which of the following guiding principles?

    • Central cyanosis is best identified around the umbilicus

    • Central cyanosis may be due to a cold room, venous obstruction, or anxiety

    • Sluggish or reduced blood flow contribute to peripheral cyanosis

    • Perpheral cyanosis is best identified in the conjuctiva and tongue

    Correct Answer
    A. Sluggish or reduced blood flow contribute to peripheral cyanosis
    Explanation
    Sluggish or reduced blood flow contribute to peripheral cyanosis because when blood flow is compromised, there is less oxygenated blood reaching the peripheral tissues. This can occur due to factors such as vasoconstriction, decreased cardiac output, or obstruction of blood vessels. As a result, the tissues in the extremities, such as the fingers, toes, and lips, may appear bluish or cyanotic. Central cyanosis, on the other hand, is caused by decreased oxygen saturation in the arterial blood and is best identified by observing the lips, tongue, and oral mucosa.

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  • 26. 

    Mary L aged 48 has been taking antihypertnesive medication for 6 months.  Recently she experiences a "near fainting" episode. Whcih of the following statements will best guide the nurse assessing Mary?

    • The nurse should assiss Mary's bp with Mary supine, sitting and standing

    • Bp should be measured in both arms whenver the nurse assesses Mary

    • A fall in systolic pressure of 5-15 mmHg is significant and indicates postural hypotension

    • Causes of postual hypotension are unknown

    Correct Answer
    A. The nurse should assiss Mary's bp with Mary supine, sitting and standing
    Explanation
    The nurse should assess Mary's blood pressure in different positions (supine, sitting, and standing) because this will provide a comprehensive evaluation of her blood pressure and help determine if she has postural hypotension. By assessing her blood pressure in these positions, the nurse can identify any significant changes in systolic pressure, such as a fall of 5-15 mmHg, which would indicate postural hypotension. This information will guide the nurse in understanding the cause of Mary's near fainting episode and developing an appropriate plan of care.

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  • 27. 

    Which anatomic structure slows the spread of electrical current through the myocardium?

    • The sinoatrial (SA)node

    • The atrioventricular (AV)node

    • The atrial conducting pathways

    • The bundle of HIS

    Correct Answer
    A. The atrioventricular (AV)node
    Explanation
    The atrioventricular (AV) node is responsible for slowing down the spread of electrical current through the myocardium. This is important because it allows for proper coordination between the atria and ventricles during the cardiac cycle. By delaying the electrical signal, the AV node ensures that the atria have enough time to contract and fill the ventricles with blood before the ventricles contract. This delay is necessary for efficient pumping of blood and maintaining proper heart function.

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  • 28. 

    A client is having an ECG to evaluate an atrial dysrhythmia.  To evaluate the atrial depolarization and contraction, the jurse will focus on the client's

    • PR interval

    • ST segment

    • P wave

    • QRS complex

    Correct Answer
    A. P wave
    Explanation
    Study and Know your ECG!!!

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  • 29. 

    The nurse detects a possible irregularity in the rhythm of a client's pulse and will

    • Count the client's apical pulse for a full minute

    • Record this as normal for the client

    • Use a stethoscope to check the brachial pulse

    • Count the radial pulse again for 15 seconds and multiply by 4

    Correct Answer
    A. Count the client's apical pulse for a full minute
    Explanation
    When a nurse detects a possible irregularity in the rhythm of a client's pulse, counting the client's apical pulse for a full minute is the appropriate action. The apical pulse is measured by placing the stethoscope on the chest over the apex of the heart and counting the number of beats for a full minute. This method provides a more accurate assessment of the heart's rhythm compared to counting the radial pulse. By counting the apical pulse for a full minute, the nurse can gather more comprehensive information about the client's heart rate and rhythm, which can help in identifying any irregularities or abnormalities.

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  • 30. 

    Which of the following is accurate regarding the S1 heart sound?

    • It is caused by the opening of the mitral and closing of the tricupsid valves

    • It has a higher pitch than the second heart sound

    • It is recorded as normal if a splitting of the sound is heard

    • It is normally heard loudest at the apex of the heart

    Correct Answer
    A. It is normally heard loudest at the apex of the heart
    Explanation
    The S1 heart sound is the first sound heard during the cardiac cycle and is caused by the closure of the mitral and tricuspid valves. It has a lower pitch than the second heart sound. The splitting of the sound is abnormal and indicates a heart condition. The S1 heart sound is normally heard loudest at the apex of the heart, which is the lower left side of the chest.

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  • 31. 

    Which of the following statements is correct regarding an arterial bruit

    • It may be be an indicator of dehydration

    • It is a low pictched blowing sound heard normally over large arteries

    • It is best detected using the diaphram of the stethoscope

    • It is often indicative of atherosclerosis

    Correct Answer
    A. It is often indicative of atherosclerosis
    Explanation
    An arterial bruit is a high-pitched blowing sound that is often indicative of atherosclerosis. Atherosclerosis is a condition where the arteries become narrowed and hardened due to the buildup of plaque. This narrowing can disrupt the smooth flow of blood, causing turbulence and producing the bruit sound. Therefore, the correct statement is that an arterial bruit is often indicative of atherosclerosis.

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  • 32. 

    Which of the following statements about using the bell of stethoscope to assess heart sounds is correct?

    • It is ineffective for detecting murmurs or rubs

    • None of these

    • It must be placed lightly on the skin

    • It is most useful for hearing high pictched sounds

    Correct Answer
    A. It must be placed lightly on the skin
    Explanation
    The correct answer is that the bell of the stethoscope must be placed lightly on the skin. The bell is the smaller side of the stethoscope, and it is designed to detect low-frequency sounds such as murmurs or rubs. Placing it lightly on the skin allows for better conduction of these sounds and helps to minimize any interference or distortion. Pressing too hard may dampen the sounds or make it difficult to hear them accurately. Therefore, it is important to use the bell of the stethoscope with a light touch for assessing heart sounds.

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  • 33. 

    An S3 or S4 is generally indicative of heart failure in an adult

    • True

    • False

    Correct Answer
    A. True
    Explanation
    An S3 or S4 heart sound is typically associated with heart failure in adults. These abnormal sounds occur during the filling phase of the cardiac cycle and indicate impaired ventricular function. The S3 sound, also known as a ventricular gallop, is caused by rapid filling of the ventricles and is often heard in conditions such as congestive heart failure. The S4 sound, also known as an atrial gallop, occurs when the atria contract forcefully to push blood into a stiff or hypertrophic ventricle. Therefore, the statement that an S3 or S4 is generally indicative of heart failure in an adult is true.

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  • 34. 

    Which of the following statements regarding arterial pulses is INCORRECT?

    • The posterior tibial pulse may be palpated on the outer aspect of the ankle

    • An arterial pulse is a pressure wave generated fromt he left ventricle to the aorta to the periperal arteries

    • The nurse should assess and compare pulses on both sides of the body

    • Occuluding the radial artery, as in the Allen test, determines patency of the ulnar artery

    Correct Answer
    A. The posterior tibial pulse may be palpated on the outer aspect of the ankle
    Explanation
    The posterior tibial pulse is actually palpated on the inner aspect of the ankle, not the outer aspect.

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  • 35. 

    When ausculating heart sounds, what do you assess?

    • Presence of rubs or murmurs

    • Rhythm

    • Rate

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    When auscultating heart sounds, you assess the presence of rubs or murmurs, the rhythm, and the rate. This means that you listen for any abnormal sounds such as rubbing or whooshing sounds, you observe the regularity of the heartbeat, and you determine the number of beats per minute. By assessing all of these factors, you can gather important information about the overall health and function of the heart.

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  • 36. 

    When taking a bp which of the following is INCORRECT

    • Inflate the cuff 30mmHg above the point at which the radial or brachial pulse disappeared on palpation

    • Remember that a systolic of 100 plus age in years is normal

    • When using a mercury sphygmomanometer, view the meniscus at eye level

    • Support the patients arm at heart level

    Correct Answer
    A. Remember that a systolic of 100 plus age in years is normal
    Explanation
    The statement "remember that a systolic of 100 plus age in years is normal" is incorrect because it is not a universally accepted guideline for determining normal blood pressure. Blood pressure can vary greatly among individuals and is influenced by various factors such as overall health, lifestyle, and medical conditions. Therefore, it is important to consider a range of factors when assessing blood pressure and not rely solely on a formula based on age.

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  • 37. 

    When the nurse gathers baseline information on a client, the nurse will check the bp in both arms to detect deficits. There should be no more than how many mmHg difference between the two?

    • 15

    • 25

    • 18

    • 10

    Correct Answer
    A. 15
    Explanation
    When the nurse gathers baseline information on a client, checking the blood pressure in both arms is important to detect any deficits. The nurse should look for no more than a 15 mmHg difference between the blood pressure readings in the two arms. This is because a significant difference in blood pressure between the arms could indicate underlying cardiovascular problems or arterial blockages. Therefore, it is crucial for the nurse to assess and compare the blood pressure in both arms to ensure accurate baseline information and identify any potential health issues.

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  • 38. 

    Mrs Jones has been admitted to your unit complaining of left sided weakness and difficulty speaking.  From the following assessments, identify the data that BEST represents a NURSING assessment

    • Left sided weakness and speech deficit indicates probable stroke

    • Neurological exam reveals partial paralysis and aphasic speech

    • Brain scan shows evidence of a clot in the middle cerebral artery

    • Unable to communicate basic needs and perform hygiene measures with left hand

    Correct Answer
    A. Unable to communicate basic needs and perform hygiene measures with left hand
    Explanation
    The data "unable to communicate basic needs and perform hygiene measures with left hand" represents a nursing assessment because it focuses on the patient's functional abilities and limitations related to their left-sided weakness and difficulty speaking. This information helps the nurse understand the patient's specific needs and develop a care plan to address them.

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  • 39. 

    Assessment of the neurogoic system includes the following areas

    • Sensory and motor function, and reflexes

    • Mental and emotional status

    • Cranial nerve assessment

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    The correct answer is "all of the above" because the assessment of the neurogoic system includes evaluating sensory and motor function, reflexes, mental and emotional status, and cranial nerve assessment. This means that in order to fully assess the neurogoic system, all of these areas need to be examined.

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  • 40. 

    What is the most reliable indicator of a change in neurologic status in a conscious patient?

    • Pupil reaction

    • Motor strength

    • Cranial nerve abnormality

    • Level of consciousness

    Correct Answer
    A. Level of consciousness
    Explanation
    The level of consciousness is the most reliable indicator of a change in neurologic status in a conscious patient. Changes in consciousness, such as confusion, disorientation, or loss of consciousness, can indicate a variety of neurologic conditions or injuries. Monitoring the level of consciousness allows healthcare providers to assess the patient's neurologic function and determine the appropriate course of action. Pupil reaction, motor strength, and cranial nerve abnormalities can also provide valuable information, but they may not be as reliable or sensitive as changes in the level of consciousness.

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  • 41. 

    Mr Toms aged 28 years was admitted the previous evening following a concussion while playing rugby. The RN asks you the following questions. What are the four qauick elements of a neurological check

    • Orientation,memory, pupils, motor strength

    • Short-term memory, pupils, cranial nerves, vital signs

    • Consciousness, cranial nerves, motor response, pupils

    • Arousal, gag reflex, motor response, pupils

    Correct Answer
    A. Orientation,memory, pupils, motor strength
    Explanation
    The four quick elements of a neurological check are orientation, memory, pupils, and motor strength. These elements are important in assessing the overall neurological function of a patient. Orientation refers to the patient's awareness of person, place, and time. Memory assessment helps determine the patient's ability to retain and recall information. Pupil examination provides information about the function of the cranial nerves and can indicate potential brain injury. Motor strength assessment evaluates the patient's ability to move and control their muscles, which can indicate any motor deficits or abnormalities.

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  • 42. 

    The Glasgow Coma Scale (GCS) is used to evaluate

    • Level of consiousness

    • Orientation

    • Pupil responses

    • Motor dysfunction

    Correct Answer
    A. Level of consiousness
    Explanation
    The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in a person. It evaluates the individual's ability to open their eyes, respond to verbal commands, and demonstrate motor responses. By assessing these factors, healthcare professionals can determine the severity of a brain injury or neurological condition. The GCS helps in monitoring and tracking changes in consciousness over time, allowing for appropriate medical interventions and treatment plans to be implemented.

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  • 43. 

    Hemianopsia (or hemianopia)

    • Is associated with dysfunction of cranial nerve three

    • Refers to the loss of right, left or bi-temporal peripheral vision

    • Is associated with dysfunction of cranial nerve eight

    • Refers to the loss of vestibular function

    Correct Answer
    A. Refers to the loss of right, left or bi-temporal peripheral vision
    Explanation
    Hemianopsia, also known as hemianopia, refers to the loss of peripheral vision on either the right, left, or both sides. This condition is not associated with dysfunction of cranial nerve three or eight, and it does not refer to the loss of vestibular function. Hemianopsia occurs due to damage or injury to the visual pathways in the brain, typically in the occipital lobe. This can result from various causes such as stroke, brain tumors, or trauma. Individuals with hemianopsia may have difficulty seeing objects or people on the affected side, leading to potential safety concerns and challenges with daily activities.

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  • 44. 

    Having the client/patient stand with feet together and eyes closed is a test of

    • Cerebellar function

    • Paresthesia

    • Superficial reflexes

    • The trochlear nerve

    Correct Answer
    A. Cerebellar function
    Explanation
    Having the client/patient stand with feet together and eyes closed is a test of cerebellar function. The cerebellum is responsible for coordinating voluntary movements, maintaining balance, and controlling posture. This test, known as the Romberg test, assesses the cerebellum's ability to integrate sensory information from the proprioceptors in the muscles and joints to maintain balance. If the client/patient sways or loses balance with their eyes closed, it suggests dysfunction in the cerebellum.

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  • 45. 

    James Feld, aged 67 years, experienced a cerebrovasuclar accident (CBA). He is able to answer yes or no to simple questions, but has difficulty speaking.  His words are difficult to understand, although he continues to make efforts to speak. Mr Feld is most likely experiencing

    • Willis or paraphasia

    • Global aphasia

    • Wernicke's or receptive aphasia

    • Broca's, or motor aphasia

    Correct Answer
    A. Broca's, or motor aphasia
    Explanation
    James Feld's difficulty in speaking, despite being able to answer yes or no to simple questions, suggests that he is experiencing Broca's, or motor aphasia. This condition is characterized by difficulty in producing speech due to damage to the frontal lobe of the brain, specifically Broca's area. It affects the ability to form words and sentences, but comprehension and understanding of language remain intact. This explains why Mr. Feld's words are difficult to understand, but he continues to make efforts to speak.

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  • 46. 

    Pain responses, both psychological and physiological, are initiated at the

    • 5th thoracic level

    • Cortical level

    • Medulla level

    • Cervial spine level

    Correct Answer
    A. Cortical level
    Explanation
    Pain responses, both psychological and physiological, are initiated at the cortical level. This means that the brain's cortex is responsible for processing and experiencing pain. The cortex is the outer layer of the brain and plays a crucial role in sensory perception, including the perception of pain. It receives and interprets signals from various parts of the body, including the nerves that transmit pain sensations. Therefore, the correct answer is cortical level.

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  • 47. 

    A person should he able to maintain his/her balance when standing on one foot for

    • 5 seconds on either side

    • 10 seconds on either side

    • An equal length of time on each side

    • 5 seconds on either side and touching one's nose

    Correct Answer
    A. 5 seconds on either side
    Explanation
    A person should be able to maintain their balance when standing on one foot for 5 seconds on either side because this demonstrates good stability and control over their body. Being able to balance equally on both sides indicates a well-developed sense of proprioception and core strength. It also suggests that the person has good coordination and is able to distribute their weight evenly. The ability to touch one's nose while balancing is not mentioned in the question and therefore not relevant to the correct answer.

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  • 48. 

    When collecting subjective data froma person during a neurological assessment, you will ask about

    • Headaches

    • Tingling or numbness

    • Diffiulty swallowing

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    During a neurological assessment, it is important to collect subjective data from the person to understand their symptoms and potential neurological issues. Headaches can be indicative of various neurological conditions. Tingling or numbness can be a sign of nerve damage or compression. Difficulty swallowing can be a symptom of a neurological disorder affecting the muscles involved in swallowing. Therefore, asking about all of these symptoms is necessary to gather comprehensive subjective data for a neurological assessment.

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  • 49. 

    You are testing the corneal reflex on a 14 year old boy with normal vision. He displays no blinking to corneal touch.  This is an abnormal finding.

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The corneal reflex is a protective reflex that causes blinking in response to any touch or irritation of the cornea. It is mediated by the trigeminal nerve (cranial nerve V). In a normal individual, the corneal reflex should be present and cause blinking when the cornea is touched. However, in this case, the 14-year-old boy with normal vision does not display any blinking to corneal touch, which is an abnormal finding. Therefore, the correct answer is true.

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  • Current Version
  • Mar 21, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Nov 12, 2013
    Quiz Created by
    TaniaChaney

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