NCLEX Assessment questions – Flashcards
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The night shift nurse reports that a client admitted with a COPD has normal capillary refill. What capillary refill time would the nurse expect to find if the client's refill time remains normal? A) 4-5 seconds B) 1-3 seconds C) 6-7 seconds D) 0-2 seconds
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Answer: B) 1-3 seconds. The process whereby blood returns to a portion of the capillary system after its blood supply has been interrupted briefly. Capillary refilling is tested by pressing firmly on a fingernail and estimating the time required for blood to return after pressure is released. In a normal person with good cardiac output and digital perfusion, capillary refilling should take less than 3 seconds. A time of more than 3 seconds is considered a sign of sluggish digital circulation, and a time of 5 seconds is regarded as abnormal.
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While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this sound as: A) S3 B) S1 C) PMI D) S4
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Answer: A) S3. A third heart sound. S3 results from the impact of inflowing blood against a distended or incompliant ventricle in mid diastole. It is a low-frequency sound occurring ~120-150 msec after S2. To improve your chances of hearing an S3, roll the patient on his or her left side (the left lateral decubitus position) to swing the cardiac apex against the chest wall, bringing it closer to your stethoscope chest piece.
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The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are? A) Pleural rub B) Stridor C) Wheezes D) Fine crackles
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Answer: D) Fine crackles. Fine crackles are brief, discontinuous, popping lung sounds that are high-pitched. Crackles, previously termed rales, can be heard in both phases of respiration. Early inspiratory and expiratory crackles are the hallmark of chronic bronchitis. Late inspiratory crackles may mean pneumonia, CHF, or atelectasis. Pleural rubs are discontinuous or continuous, creaking or grating sounds. Because these sounds occur whenever the patient's chest wall moves, they appear on inspiration and expiration. Stridor is a loud, high-pitched crowing breath sound heard during inspiration but may also occur throughout the respiratory cycle most notably as a patient worsens. Stridor is caused by upper airway narrowing or obstruction. Causes of stridor are pertussis, croup, epiglottis, aspirations. Wheezes are adventitious lung sounds that are continuous with a musical quality.The proportion of the respiratory cycle occupied by the wheeze roughly corresponds to the degree of airway obstruction. Wheezes are caused by narrowing of the airways.
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A 46-year old client is admitted for a rountine outpatient surgery. Before surgery, the nurse auscultates the client's chest for breath sounds. Identify the area where the nurse should expect to hear bronchiovesicular breath sounds? A) Upper third of the sternum and between the scapula. B) Midline to the umbilicus C) Largest lung surface area D) Over the trachea
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Answer: A) Upper third of the sternum and between the scapula. Bronchiovesicular breath sounds are best heard next to the upper third of the sternum and between the sacpule. These breath sounds are equal in length during inspiration and expiration. They reflect a mixture of the pitch of the bronchial breath sounds heard near the trachea and the alveoli with the vesicular sound. Vesicular sounds are most commonly auscultated heard over the most of the lung surface, they are soft and low pitched with a rustling quality during inspiration and are even softer during expiration. Bronchial breath sounds can be auscultated over the trachea where they are considered normal, they are hollow, tubular sounds that are lower pitched.
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An 76-year old female client comes in the Emergency Department complaining of shortness of breath. When listening to the client's lungs, the nurse hears crackles during inspiration. What conditions might cause the nurse to hear crackles upon auscultation? Select all that apply. A) Acute respiratory distress syndrome (ARDS) B) Asthma C) Pneumonia D) Pulmonary edema E) Pectus Carinatum
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Answer: A, C, D. Crackles are discontinuous, explosive, "popping" sounds that originate within the airways. They are significant as they imply either accumulation of fluid secretions or exudate within airways or inflammation and edema in the pulmonary tissue. Crackles, previously termed rales, can be heard in both phases of respiration. Early inspiratory and expiratory crackles are the hallmark of chronic bronchitis. Late inspiratory crackles may mean pneumonia, CHF, or atelectasis.
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Which statement is true for a patient who has pathology in Wernicke's area of the cerebrum? A) Receptive speech is affected B) The occipital lobe is involved. C) Vision processing is abnormal. D) An abnormal Romberg test is present.
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Answer: A) Receptive speech is affected. The temporal, not parietal, lobe contains the Wernicke area, which is responsible for receptive speech and integration of somatic, visual, and auditory data.Vision processing occurs in the occipital lobe. The Romberg test is used to assess the equilibrium.
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When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity. How would you accurately document this assessment finding? A) Athetosis B) Hypotonia C) Hemiparesis D) Pronator drift
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Answer: D) Pronator drift. Downward drifting of the arm or pronation of the palm is identified as pronator drift. Hemiparesis is weakness of one side of the body, hypotonia describes flaccid muscle tone, and athetosis is a slow, writhing, involuntary movement of the extremities. Athetosis is a continuous stream of slow, flowing, writhing involuntary movements. Hypotonia is the medical term for decreased muscle tone. Hemiparesis is weakness of the entire left or right side of the body.
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A client comes to the clinic for a routine checkup. To check the client's gag reflex, the nurse should use which method? A) Have the client to cough B) Place the tongue blade lightly on the posterior aspect of the tongue C) Have client to place index finger in back of throat D) Place tongue blade lightly on the anterior aspect of the tongue
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Answer: B) Place the tongue blade lightly on the posterior aspect of the tongue. A gag reflex can be elicited by mere light touching of the posterior wall of the oropharynx with a tongue blade. The patient should have immediate elevation of the palate, the muscles of the pharynx should constrict, and the patient should begin making gagging sounds indicating a normal gag reflex. If none of this happens the gag reflex has not returned. Having the client to cough, use their index finger, and placing tongue blade on anterior portion of the tongue does not allow the nurse to properly assess the gag reflex.
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The nurse has received shift report. Which client should the nurse assess first? A)Client with abdominal pain 4/10 on numeric scale, medication have been given B)Client with COPD whose oxygen saturation is 78% C)Client returning from a MRI with stable vital sign D)Client diagnosed with dehydration
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Answer: B) Client with COPD whose oxygen saturation is 78% Airway - what could cause it to be blocked? Trauma, mucus, etc. One nursing dx is ineffective airway clearance. Breathing - anything having to do with the act of breathing -- respiration rate and depth (ineffective breathing pattern) or gas exchange in the lungs (ineffective gas exchange). Circulation - anything to do with the vascular system. Think bleeding, cardiac output, dehydration, fluid overload, etc. Decreased cardiac output, fluid volume deficit/excess, risk for bleeding. Then you go with Maslow's hierarchy for your prioritization. Pain before coping, food before love, etc.
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The nurse is enters a client's room diagnosed with increased ICP. Upon, inspection the nurse notes the client in a flat supine position. The nurse knows that the best way to position the client with increased ICP is to? A) Keep the head of the bed flat. B) Maintain patient on the left side with the head supported on a pillow. C) Elevate the head of the bed to 30 degrees. D) Use a continuous-rotation bed to continuously change patient position
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Answer: C) Elevate the head of the bed to 30 degrees. You should maintain the patient with increased ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. Careful evaluation of the effects of elevation of the head of the bed on the ICP is required.
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A nurse asks a client to close her eyes, and then places a paper clip in the client's palm. The client correctly identifies the object. What neurological assessment did the nurse perform? A) Tactile discrimination B) Graphesthesia C) Extinction D) Stereognosis
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Answer: D) Stereognosis Stereognosis is the act of recognizing objects by touching and manipulating them. Tactile discrimination is the ability to differentiate information received through the sense of touch. Graphesthesia is ability to feel writing on the skin. Extinction is failure to perceive touch on one side of the body when both sides are touched simultaneously. One- and two-point discrimination entail the ability to sense if one or two areas of the skin, respectively, are being stimulated by pressure.
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A client asks the nurse, "What is the purpose of a physical examination?" Which response by the nurse is correct? Select all that apply. A) To supplement, confirm, or refute data obtained in the nursing history B) To obtain baseline data about the client's functional abilities C)To obtain data that will help establish nursing diagnoses and plans of care D) To determine if the client is telling the the truth about their health E)To evaluate the physiologic outcomes of health care and thus the progress of a client's health problem
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Answer: A, B, C, E. These are some of the purposes of the physical examination: To obtain baseline data about the client's functional abilities; To supplement, confirm, or refute data obtained in the nursing history; To obtain data that will help establish nursing diagnoses and plans of care; To evaluate the physiologic outcomes of health care and thus the progress of a client's health problem; To make clinical judgments about a client's health status; To identify areas for health promotion and disease prevention; The nurse is not trying to determine if the client is being dishonest.
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The nurse is palpating the precordial surface of an adult and notes a mild pulsation in the fifth intercostal space at the midclavicular line. What does this finding suggest to the nurse? A)This is a normal finding and the location of the point of maximum impulse (PMI) B)This is abnormal finding and needs to be reported immediately C)This is normal finding and the location of the pulmonic valve area D)This is a normal finding and the location of the tricuspid valve
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Answer: A) This is a normal finding and the location of the point of maximum impulse (PMI). Mitral Area is located at the left ventricular area, 5th intercostal space at the midclavicular line. This is where you can find the Apical Pulse and usually can find the Point of Maximum Intensity (PMI). The Pulmonic Area is located at the second interspace to the left of the sternum. The Tricuspid Area is located at the right ventricular area, 4-5th interspace; lower half of the sternum.
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During a cardiovascular assessment the nurse notes that the client has a heart rhythm with a pause after each beat and a skip every third beat. What is the appropriate interpretation of these findings? A) Regular B) Regularly Irregular C) Atrial Fibrillation D) Irregularly Irregular
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Answer: B) Regularly Irregular Regularly Irregular has a regular patterm overall with "skipped" beats. Regular is evenly spaced beats and may vary slightly with respiration. Irregularly Irregular is chaotic, with no real pattern, very difficult to measure rate accurately. Atrial fibrillation creates irregular, hectic signals for your heart.
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A nurse is conducting an physical assessment on a client's lungs. The nurse ask the client to say ninety-nine several times in a normal voice to feel vibrations that could suggest consolidation. What asasessment tests could the nurse perform using this method? Select all that apply. A) Egophony B) Bronchophony C)Tactile Fremitus D) Whispered Pectorilquy E) Diaphragmatic Excursion
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Answer: B, C, D. Ask the patient to say "99" several times while auscultating the chest walls. Over consolidated areas "99" is understandable. This is because acoustic filtering is reduced in consolidated lung tissue, which allows better sound transmission. During auscultation, louder, clearer sounds are called bronchophony, the sound should be muffled and indistinct. You should only hear faint sounds or nothing at all with whispered pectorilquy, if you hear sounds clearly consolidation is present. Tactile fremitus uses the ball of the hand to feel vibrations transmitted through the airways to the lung. Increased tactile fremitus suggests consolidation of the underlying lung tissue.
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A nurse is assessing a client in the Emergency Department with complaints of left shoulder pain. During range of motion, the client complained of increased pain. The nurse performs a Impingement sign test on the client to check the rotator cuff. The nurse must do which of the following to perform this test properly? A) Ask the client to slowly lower the arm after ROM B) Press firmly straight down with index finger or thumb C) Abduct the arm 90 degrees D) Palpate the scaphoid area
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Answer: C) Abduct the arm 90 degrees Impingement sign test starts with the clients arm relaxed and the shoulder in the neutral rotation. Abduct the arm 90 degrees. Significant shoulder pain as the arm is raised suggests an impingement of the rotator cuff against the acromion. Asking the client to slowly lower the arm is the Drop arm test, if the client is unable to lower the arm slowly and smoothly the rotator cuff is torn. Pressing firmly straight down on the shoulder and palpating the scaphoid area is assessing for Snuffbox tenderness of the scaphoid.
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A nurse is working in the clinic. A female client complains of tingling and numbness in hand and has been to weak to hold items in her hand. The nurse should use which assessment for carpal tunnel syndrome? A) Allen test B) Tinsel's Sign test C) Flexor Profundus test D) Collateral Ligament test
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Answer: B) Tinsel's Sign test The nurse should use her middle finger or a reflex hammer to tap over the carpal tunnel. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome. An Allen test is assess the radial/ulner arteries. Flexor Profundus test is to assess the flexor digitorum profundus of the finger. Collateral ligament testing is to assess the medial collateral ligament of the knee.
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A new nurse is being oriented to an orthopedic clinic. She hears a nurse report FABER test results to the physician after her assessment. The new nurse asked the experienced orthopedic nurse "What is a FABER test?" How should the experienced orthopedic nurse respond? A) "A FABER test reveals if their femur is broken." B) " Don't worry about that right." C) "That nurse is always trying to suck up to the physicians around here." D) " FABER stands for Flexion, ABduction, and External Rotation of the hip."
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Answer: D) "FABER stands for Flexion, ABduction, and Extrenal Rotation of the hip." The experienced orthopedic nurse should explain what the test is and provide information on the assessment. During a FABER test the client should lie supine, place foot of the effected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gently on the flexed knee and opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.
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A nurse plans to assess a client's coordination and gate. The nurse ask the client to stand with feet together and eyes closed for 5-10 seconds without support. What assessment is the nurse using to test the client's coordination? A) Romberg B) Pronator Drift C) Weber test D) Point-to-Point movement
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Answer: A) Romberg With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability. These are vision, proprioception, and vestibular sense. If there is a mild lesion in the vestibular or proprioception systems, the patient is usually able to compensate with the eyes open. When the patient closes their eyes, however, visual input is removed and instability can be brought out. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position even with their eyes open. Note that instability can also be seen with lesions in other parts of the nervous system such as the upper or lower motor neurons or the basal ganglia, so these should be tested for separately in other parts of the exam. Pronator drift can indicate that the arm's motor control center on the opposite side of the brain isn't functioning properly. Weber test is for hearing. Point-to-Point movements does test for coordination by touching index finger to the nose several times.
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A nurse is assessing the muscle strength of a client admitted with right sided weakness. The nurse notes that there is slight mucsle movement, but no movement at the joint. How should the nurse document this assessment in the chart? A) 5/5: normal strength B) 1/5: muscle flicker, but no movement C) 3/5: movement possible against gravity, but not against resistance by the examiner D) 2/5: movement possible, but not against gravity
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Answer: B) 1/5: muscle flicker, but no movement Patterns of weakness can help localize a lesion to a particular cortical or white matter region, spinal cord level, nerve root, peripheral nerve, or muscle. 0/5: no muscle movement 1/5: muscle flicker, but no joint movement 2/5: movement at the joint possible, but not against gravity 3/5: movement possible against gravity, but not against resistance by the examiner 4/5: movement possible against some resistance by the examiner , but less than normal 5/5: normal strength
