Head to Toe

A patient tells you they are in a lot of pain. What do you do next?

• Record it as a subjective finding

• offer them pain medication

• use the Glascow scale to gather more information

• Ask them to rate it on a scale of 0-10

A nurse has finished examining a client's nose and sinuses and is about to examine the client's mouth and throat. What would be most important for the nurse to do?

• Warm the hands

• put on gloves

• obtain a tuning fork

• collect a saliva specimen

A nurse is performing an abdominal assessment. The correct order of assessment techniques would be

• inspect, auscultate, lightly palpate, deeply palpate

• inspect, auscultate, deeply palpate, lightly palpate

• inspect, lightly palpate, auscultate, deeply palpate

• inspect, deeply palpate, lightly palpate, auscultate

What would a nurse ensure before beginning a health assessment?

• That the time needed for the assessment fits into the nurse's work schedule.

• That the room is private, quiet, warm, and has adequate light.

• That family members are present to answer specific questions.

• That there is a written physician's order for the assessment.

The nurse includes a percussion hammer in the assembled equipment to be used during a client's physical examination. The percussion hammer will be used to assess which of the following?

• Deep tendon reflexes

• Auditory function

• Vibratory perception

• Tympanic membrane function

The nurse has palpated a client's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted?

• The client's weak pulses may be indicative of cardiovascular disease.

• The client has normal peripheral pulses.

• The client has increased radial pulses that may result from hypertension.

• The client shows no signs of a circulatory health problem.

You are assessing the lower extremities. Which of the following pulses will you assess?

• Popliteal

• Dorsalis Pedis

• Posterior Tibial

• Brachial

• Ulnar

A patient comes to the ER with respiratory distress. What is your priority?

• Gather history to determine if they have respiratory illness

• Gather history to determine if they have cardiac illness

• provide Oxygen

• Assess airway

What are the signs of respiratory distress?

Select all that apply

• Crying

• Grunting

• Flaring

• Retracting

• fever

You are teaching a class about nutrition to a group of adolescents. Which level of prevention is this?

• primary

• secondary

• tertiary

• educational