Health Assessment 1 End Chapter Review

The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the

a) preinteraction phase.

b) beginning phase.

c) working phase.

d) closing phase.

C. Working phase.

Rationale: During the working phase, the nurse collects data. The preinteraction phase is when the nurse looks at the chart before talking with the patient. In the beginning, the nurse introduces self and at the closing summarizes.

When assessing a child, the nurse makes the following adaptation to the usual techniques:

a. A pediatric stethoscope is used for better contact.

b. The child is seated away from the parent.

c. The room is full of toys for play.

d. The child is undressed, including the diaper.

A. A pediatric stethoscope is used for better contact.

Rationale: A pediatric stethoscope is smaller than the adult-sized one, allowing for the full diaphragm to be sealed on the patient's skin. The parent may wish to hold the child for security and comfort. If the room is full of toys, the child may prefer to play and be hesitant to be examined. The child is kept covered as much as possible to avoid chilling; when clothes are removed, the diaper usually partly covers the genitals to prevent the child from involuntarily urinating on the examiner.

All formats of progress notes

a. use the nursing process in some form to show nursing thinking.

b. identify the patient outcomes or goals to evaluate.

c. include head-to-toe assessment data for completeness.

d. have a section for evaluation of care so that nurses may revise interventions.

A. Use the nursing process in some form to show nursing thinking.

Rationale: Types of progress notes include narrative, SOAP, PIE, and focus notes. Nurses arrange narrative notes, which are the most loosely organized, by time or topic; they also usually cluster data and include some interventions in these notes. SOAP, PIE, and focus notes allow nurses to cluster data and reflect the critical thinking and diagnostic reasoning they used to plan and evaluate care. Case notes, care plans, or care maps may include patient outcomes or goals. They usually include an evaluation section near the outcomes. Usually, the assessment information focuses on the problem, and nurses write the complete head-to-toe information on an assessment flow sheet.

The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient

a. clench their teeth during muscle palpation.

b. bring their head to the chest.

c. turn their head against resistance.

d. extend their arms against resistance.

C. Turn their head against resistance.

Rationale: The sternocleidomastoid muscles play an important role in turning the head from side to side. Asking the patient to turn the head against resistance is one way to determine that the strength of these muscles is symmetrical and equal.

While reviewing laboratory values for thyroid function in an adult patient, the nurse sees that the TSH is elevated, and T3 and T4 are decreased. The nurse recognizes that these findings are indicative of

a. normal thyroid function.

b. hypothyroidism.

c. hyperthyroidism.

d. thyroid cancer.

B. Hypothyroidism.

Rationale: With hypothyroidism, TSH from the pituitary gland usually is increased. Because of decreased thyroid function, there is a decrease in circulating thyroid hormones as measured by T3 and T4 levels in the blood.

While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for:

a. dizziness.

b. bowel/bladder incontinence.

c. difficulty swallowing.

d. arm weakness.

B. Bowel/bladder incontinence.

Rationale: Dizziness and difficulty swallowing are potential signs of cerebral rather than spinal cord lesions. Arm weakness from spine problems would indicate cervical injury (with associated neck rather than back pain). Bowel and bladder incontinence can occur with spinal cord injury at any level.

The nurse documents the following information in a patient's chart: "Cough and deep breathe every hour while awake." This is an example of

a) evidence-based nursing.

b) priority setting.

c) comprehensive assessment.

d) nursing interventions.

D. Nursing interventions.

Rationale: Nursing interventions are actions taken by the nurse to promote health. They usually begin with a verb and have a time frame.

A patient says that they are having throbbing pain that they rate as 6 on a 10-point scale. This is referred to as

a) subjective primary data.

b) subjective secondary data.

c) objective primary data.

d) objective secondary data.

A. Subjective primary data.

Rationale: Subjective data are open to interpretation; only the patient knows what they are. Objective data are measurable and visible signs, such as a facial grimace. Patients report primary data; nurses collect secondary data from other sources such as the family, chart, or staff. Pain is what the patient says it is.

The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is

a) "Don't cry. It will be OK."

b) "My mother has the same thing."

c) "I think that you should have surgery."

d) "I'll stay with you" (gets a tissue).

D. "I'll stay with you" (gets a tissue).

Rationale: Being present and using silence are effective tools in such circumstances. A is false reassurance, B is too personal, and C is giving unwanted advice.

When gathering the family history, the nurse draws a genogram

a) using circles for males and squares for females.

b) putting the patient on the left to show birth order.

c) inserting lines between parents to show marriage.

d) listing health problems above the symbol for the patient.

C. Inserting lines between parents to show marriage.

Rationale: Lines between parents show marriages; a double slash through the line indicates divorce

The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is

a) "You must be extremely worried."

b) "I'd be in worse shape than you are if it were my baby."

c) "Is there anyone here that you can talk to?"

d) "You seem worried, but I need to ask a few questions."

D. "You seem worried, but I need to ask a few questions."

Rationale: This is an emergency assessment, so it is important to gather the history. While acknowledging that the mother is worried, D also focuses the conversation back on the infant. Once the infant is stabilized, the nurse will have the opportunity to talk with the mother about her feelings.

To assess self-perception, the nurse asks

a) "How would you describe yourself?"

b) "Are you having difficulty handling any family problems?"

c) "What gives you hope when times are troubled?"

d) "How do you usually deal with stress? Is it effective?"

A. "How would you describe yourself?"

Rationale: Assessment of self-perception focuses on how the patient thinks about themself. Role addresses the daily duties or tasks. Values address important big concepts of life and death. Coping is in response to a stressor.

The nurse assessing an older adult focuses the health history on

a) previous pregnancies, obstetric history, and psychosocial factors.

b) birth history, immunizations, and growth and development.

c) sensory deficits, illness history, and lifestyle factors.

d) religion, spirituality, culture, and values.

C. Sensory deficits, illness history, and lifestyle factors.

Rationale: Includes items that are significant with aging. Pregnancies and obstetric history are pertinent to the pregnant female. Birth history, immunizations, and growth history are most important for children to identify the risk for problems, provide primary prevention, and assess for current problems. Religion and culture are assessed during the cultural assessment.

The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking

a) uses subjective data to analyze findings and intervene.

b) documents and communicates data using appropriate medical terminologies.

c) individualizes health assessment considering the age, gender, and culture of the patient.

d) uses assessment findings to identify medical and nursing diagnoses

A. Uses subjective data to analyze findings and intervene.

Rationale: The nurse is using data from the assessment to begin the nursing process—diagnosing, planning, and intervening. The last step is to evaluate care, or reassess and determine if the interventions were effective.

Which of the following interventions is most important to prevent nosocomial infections?

a) Proper glove use

b) Hand hygiene

c) Appropriate draping

d) Quiet environment

B. Hand hygiene.

Rationale: Hand hygiene is the single most important intervention to prevent the spread of infection. Either handwashing or using hand gel between patients is acceptable.

Standard precautions

a) are used on every patient because it is not always known whether a patient is infected.

b) state that hand gel is used for infection with Clostridium difficile.

c) include the use of gowns, gloves, and masks with all patients.

d) recognize that transmission-based precautions are common.

A. Are used on every patient because it is not always known whether a patient is infected.

Rationale: Standard precautions are used with every patient to prevent exposure to potential viruses, bacteria, or fungi. Hand gel is ineffective against C. difficile. Gowns, gloves, and masks are used only when there is potential contact with body secretions. Transmission-based precautions, including droplet, airborne, or contact precautions, are used with selected groups of patients who have identified infections.

Latex allergies

a) always result in anaphylactic reactions and shock.

b) can be reduced by moisturizing the hands after washing.

c) cannot be caused by equipment such as a stethoscope.

d) are more common in nurses and in frequently hospitalized patients.

D. Are more common in nurses and in frequently hospitalized patients.

Rationale: Latex allergies are more common in nurses and frequently hospitalized patients. They may result in anaphylactic or less severe reactions (e.g., difficulty breathing, itching, hives). The only way to avoid latex reactions is to avoid exposure to latex, which may be present in some stethoscopes, equipment, and stoppers of some medication vials.

Which of the following is an example of inspection?

a. Heart rate and rhythm regular

b. Lungs clear

c. Abdomen tympanic

d. Skin pink

D. Skin pink.

Rationale: Inspection involves visual information. Heart rate and rhythm regular is auscultation, lungs clear is auscultation, and abdomen tympanic is percussion.

The patient is complaining of abdominal pain. What technique is used to form an overall impression?

a. Auscultation

b. Light palpation

c. Direct percussion

d. Deep palpation

B. Light palpation.

Rationale: An overall impression of the abdomen is gained by lightly palpating for tenderness and firmness. Auscultation provides information about gastrointestinal motility. Percussion provides information about an air-filled versus a solid or fluid-filled cavity. Deep palpation is used to identify the location of organs, masses, or tumors.

Tympany is a percussion sound commonly located in the

a. thorax.

b. upper arm.

c. abdomen.

d. lower leg.

C. Abdomen.

Rationale: Percussion sounds are hyperresonant (diseased lungs), resonant (normal lungs), tympanic (abdomen), dull (over organs), and flat (over bone).

Which organs or body areas does the nurse auscultate as part of the admitting assessment?

a. Heart, lungs, and abdomen

b. Kidneys, bladder, and ureters

c. Abdomen, flank, and groin

d. Neck, jaw, and clavicle

A. Heart, lungs, and abdomen.

Rationale: The nurse auscultates heart, breath, and abdominal sounds as part of the complete assessment. All these involve movement, which generates sounds.

What technique facilitates accurate auscultation?

a. Earpieces of the stethoscope are positioned to point toward the back.

b. The tubing of the stethoscope is long and dark in color.

c. The chestpiece of the stethoscope is sealed against the skin.

d. The diaphragm of the stethoscope is used for low-frequency sounds.

C. The chestpiece of the stethoscope is sealed against the skin.

Rationale: Earpieces always point toward the front, following the same position as the nose. Tubing should be short and thick to optimize sound transmission. The chestpiece should be completely on the patient's skin to diminish transmission of room noise and to optimize sounds from the patient. The diaphragm is used for high-frequency sounds (e.g., bowel sounds); the bell is used for low-frequency sounds.

Select all of the documentation errors that are potentially high risk. (Select all that apply.)

a. Failure to document completely

b. Inadequate admission assessment

c. Charting in advance

d. Bunch charting at the end of shift

A, B, C, D. Failure to document completely, inadequate admission assessment, charting in advance, and bunch charting at the end of shift.

Rationale: All are considered high-risk assessments for liability. In addition, falsifying patient records, failure to record changes in patient condition, failure to document that the nurse notified the primary care provider when the patient's condition changed, and failure to follow agency's standards or policies on documentation are high risk.

The purpose of auditing charting is to

a. enhance nurses' learning and understanding of complex clinical situations.

b. identify staff members who document completely and counsel those who do not.

c. determine whether staff members are providing and documenting standards of care.

d. locate data in the chart the evening before a morning clinical visit.

C. Determine whether staff members are providing and documenting standards of care.

Rationale: Agencies usually perform audits to look at systems, not individuals, and to determine whether staff members are meeting the standard of care. Accrediting agencies, such as The Joint Commission or Department of Health, audit charts to make sure that an agency is meeting state or federal standards. They also may review charts for financial reimbursement, especially Medicare or Medicaid. The charts are used for learning in grand rounds, in conferences, and for individual students of the health professions. Researchers also use charts to gather retrospective data.

Select all actions that are acceptable under the HIPAA Privacy Rule. (Select all that apply.)

a) Communicate report with the next nurse during change of shift.

b) Communicate with the primary care provider about a patient's change in assessment.

c) Consult in the hall with the instructor about the patient's abnormal findings.

d) Describe patient assessment findings to a colleague in the cafeteria.

A, B. Communicate report with the next nurse during change of shift and communicate with the primary care provider about a patient's change in assessment.

Rationale: The HIPAA Privacy Rule requires an agency to make reasonable efforts to limit use of, disclosure of, and requests for protected health information to the minimum necessary to accomplish the intended purpose. Because the purposes of A and B are for the benefit of the patient, these are acceptable. Consulting with the instructor is also appropriate, but the hall is an inappropriate location to do so. Talking with a colleague is also acceptable in the context of learning, such as a postconference. Elevators, cafeterias, and other public spaces are inappropriate locations because visitors and other patients may become anxious or fearful when overhearing details related to illness, procedures, and other health-related concerns.

The proper technique for correcting written documentation is to

a. use correction fluid and write over the error.

b. completely black out the error with a black marker.

c. write over the error in darker ink.

d. draw a line through the error and write the date, time, reason for error, and your initials.

D. Draw a line through the error and write the date, time, reason for error, and your initials.

Rationale: The legal technique for correcting an error is to place a single line through it, write the word "error," and initial it. In a court of law, the court needs to see the underlying data that were corrected, and blacking out the error with a black marker, writing over the error in darker ink, or using correction fluid obstruct the initial entry.

Strategies for effective handoffs during change-of-shift report are to

a. tape-record the report for efficiency.

b. vary the format to individualize to the patient.

c. allow an opportunity to ask and answer questions.

d. put report in writing so that the next shift care provider can get right to work.

C. Allow an opportunity to ask and answer questions.

Rationale: A standardized format such as SBAR for handoffs ensures that nurses present all important information predictably and clearly. Face-to-face verbal updates of current status and historical data with interactive questioning are recommended for handoffs. It is best for nurses to perform handoffs in areas with limited interruptions, although finding such a location can be challenging during this busy time. Nurses use "readback" policies to ensure that both parties agree and comprehend high-risk procedures or medications. Verbal handoffs do not replace required written documentation because written documentation serves as the legal record. By reporting in person, nurses can cross-monitor the handoffs of others.

Nursing assessment of trends in an unconscious patient's neurological status over time is best recorded on

a. an admission assessment.

b. a POC.

c. a progress note.

d. a focused assessment flow sheet.

D. A focused assessment flow sheet.

Rationale: The focused assessment would have information just on the neurological assessment so that the treatment team could identify changes in the patient's status quickly. Nurses can incorporate data and trends into a POC and progress note to show how the assessment is a basis for interventions. Nurses use the POC to identify outcomes and direct future care so that nursing care is consistent from shift to shift. Progress notes evaluate patient progress toward outcomes. A judgment is made about progressing or not progressing toward goals. Outcomes and interventions may be revised as needed, and a reassessment is made. The admission assessment is usually performed just once, upon admission to a facility. If the patient is unconscious or the data are incomplete, the nurse adds data to the admission assessment after 24 hours.

Your patient with a humerus fracture is stating pain of 5 on a 10-point scale. Their hand is pale, cool, and swollen. The pain medication is ineffective, and they are at risk for impaired circulation. What action will the nurse take first?

a. Reassess the pain in 30 minutes and contact the provider if unresolved.

b. Give additional pain medication and reassess the pain in 30 minutes.

c. Document the abnormal findings and give an extra dose of pain medication now.

d. Contact the primary care provider and document the findings now.

D. Contact the primary care provider and document the findings now.

Rationale: Similar to the case study, this situation represents an acute emergency for which the nurse should take immediate action. Nurses communicate the assessment using the SBAR technique. In addition, they document the findings in the chart. Nurses also note the interventions, such as pain medication, effectiveness, and assessment. They document that they contacted the primary care provider and the response. If the response was unacceptable, nurses may continue to call using the chain of command or may initiate a rapid response.

The nurse assesses the following vital signs in a 78-year-old male: temperature 36.6°C, temporal; pulse 72 beats/min, regular, 2+; respirations 18 breaths/min, regular, no use of accessory muscles; BP 142/92 mm Hg. Which of the findings is abnormal?

a. Pulse

b. BP

c. Respirations

d. Temperature

B. BP.

Rationale: In older adults, both SBP and DBP increase due to increased stiffness of arterial walls. This finding is outside of the normal range. Temperature in the older adult tends to be at the lower range of normal.

The best way to assess a client's respiration rate is by

a. placing a hand over the client's chest and counting for 30 seconds.

b. observing and counting respirations for 30 seconds and multiplying by 2 without mentioning that you are observing the respirations.

c. asking the client to breathe normally for 1 minute.

d. having the client rest for 10 minutes and then recounting if respirations are irregular.

B. Observing and counting respirations for 30 seconds and multiplying by 2 without mentioning that you are observing the respirations.

Rationale: Do not make the patient aware that you are assessing respirations. Increased awareness may alter normal respiratory pattern.

Which of the following patients should not have a temperature measured orally?

a. An 84-year-old female with diarrhea

b. A 30-year-old patient with an earache

c. A 45-year-old male with chest pain

d. A 62-year-old female who has had oral surgery

D. A 62-year-old female who has had oral surgery.

Rationale: Oral temperature measurement is contraindicated in patients who have altered mental status, those who are mouth breathers, those who have had recent oral intake or who have recently smoked, and those who have recently undergone oral surgery.

The nurse notes an irregular radial pulse in a patient. Further evaluation includes assessing

a. for a pulse deficit.

b. the carotid pulse.

c. for diminished peripheral circulation.

d. the brachial pulse.

A. For a pulse deficit.

Rationale: Assessing for a pulse deficit provides an indirect evaluation of the heart's ability to eject enough blood to produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse.

Which actions will result in an inaccurate BP reading? Select all that apply.

a. Obtaining a BP immediately after the patient has entered the room.

b. Using a BP cuff with a bladder length that is 80% of the arm circumference.

c. Asking the patient to hold out their arm above heart level.

d. Pumping the cuff 10 mm Hg above the palpated SBP.

A, C, D. Obtaining a BP immediately after the patient has entered the room, asking the patient to hold out their arm above heart level, and pumping the cuff 10 mm Hg above the palpated SBP.

Rationale: Common errors in BP measurements can occur because of physical activity, incorrect cuff size, placing the arm above or below heart level, and failure to auscultate above an auscultatory gap. It is recommended to pump the cuff 20 to 30 mm Hg above the last sound.

Adult patients may have variations in pulse rates with

a. respirations.

b. food intake.

c. heat.

d. exercise.

D. Exercise.

Rationale: Exercise will increase heart rate because of increased metabolic demands. Sinus arrhythmia, a variation in pulse with respiration, is common among children. The pulse rate varies with respiration, speeding up during inspiration and slowing down during expiration.

Which of the following findings during the general survey may indicate a change in mental status? Select all that apply.

a. Disheveled appearance

b. Rapid speech

c. Lethargy

d. Asymmetrical movements

A, B, C. Disheveled appearance, rapid speech, and lethargy.

Rationale: The general survey provides valuable clues to the patient's overall status. Changes in appearance, speech, and alertness may indicate a change in mental status and require further evaluation. Asymmetrical movements may indicate a stroke and a specific change in neurological status.

The patient has pain of a short duration with an identifiable cause. This is referred to as

a. acute pain.

b. chronic pain.

c. neuropathic pain.

d. complex pain.

A. Acute pain.

Rationale: Acute pain is of short duration; chronic pain lasts more than 3 to 6 months. Neuropathic pain results from injury to a nerve related to trauma or diseases (e.g., diabetes). Complex regional pain syndrome can develop from acute pain, which is undertreated.

A patient says that their pain worsens with weight-bearing activity. The nurse would consider this

a. an alleviating factor.

b. a functional pain goal.

c. a quality/description.

d. an aggravating factor.

D. An aggravating factor.

Rationale: An alleviating factor makes the pain better. The functional pain goal is set to determine the patient's desire for activities such as exercise, driving, cooking, or dressing. The quality and description include what the pain feels like (e.g., stabbing, throbbing).

Which of the following tools would a nurse use to perform a multidimensional pain assessment?

a. Visual analogue scale

b. Brief Pain Inventory

c. Numeric pain intensity

d. Verbal descriptor

B. Brief Pain Inventory.

Rationale: The visual analogue scale (VAS) and numeric pain intensity scales are unidimensional, measuring intensity. Verbal descriptors measure pain intensity but with words instead of numbers. The Brief Pain Inventory (BPI) includes a pain intensity scale, a body diagram to locate the pain, a functional assessment, and questions about the efficacy of pain medications. Thus, the BPI is multidimensional.

Then nurse is most likely to assess pain using the McGill Pain Questionnaire to collect which data?

a. Verbal description

b. Alleviating factors

c. Functional status goal

d. Pain goal

A. Verbal description.

Rationale: The McGill Pain Questionnaire consists of a set of verbal descriptors used to capture the sensory aspect of the pain experience, a VAS, and present pain intensity rating. The alleviating factors, functional status goal, and pain goals are elements assessed during the basic elements of a pain assessment.

Which of the following indicators would be most likely to signify to the nurse that a patient is having pain?

a. Falling asleep

b. Rubbing a body part

c. Relaxed body position

d. Facial droop

B. Rubbing a body part.

Rationale: Vocalizations, facial grimacing, bracing, rubbing, restlessness, and vocal complaints are behaviors in patients with dementia who cannot accurately express their pain. Sleep is interrupted and the patient may be anxious or restless.

A patient reports pain, depression, and insomnia. The nurse observes a masklike facial expression and frequent position changes. Which of the following is the nurse most likely to use to describe the patient's findings?

a. Acute pain

b. Chronic pain

c. Neuropathic pain

d. Chronic regional pain syndrome

B. Chronic pain.

Rationale: Acute pain behaviors include increased pulse, respiration, and blood pressure; nausea; and reports of pain. Patients tend to describe neuropathic pain as tingling, burning, or numbness. Those with complex regional pain syndromes report high levels of pain and begin to experience loss of function, temperature sensitivity, swelling, or other skin changes, such as hair loss in the affected area.

With which of the following types of patients is the nurse most likely to use the FACES pain scale?

a. Children

b. Patients with dementia

c. Older adults

d. Unconscious patients

A. Children.

Rationale: FACES is most commonly used with children. A common scale for assessing pain in patients with dementia is the Pain Assessment in Advanced Dementia Scale (PAINAD), which includes breathing, negative vocalizations, facial expression, body language, and consolability. The Payen Behavioral Pain Scale is common for unconscious patients.

Which of the following is the rationale for the nurse to reassess the patient's pain after treatment?

a. To pinpoint the pain's location

b. To measure the pain's duration

c. To establish the efficacy of medication

d. To make changes to the patient's pain goal

C. To establish the efficacy of medication.

Rationale: Location means where the patient experiences pain; this is not expected to change in a reassessment. Duration is how long the patient experiences pain; the rationale for the 30- to 60-minute time frame for reassessment is to allow the pain medication to take effect. The pain goal is negotiated on admission rather than readmission. The shorter pain reassessment is performed to assess the efficacy of treatment.

Which of the following is a barrier to pain assessment?

a. The nurse believes that patients suffer if undermedicated.

b. The nurse focuses on pain relief as a primary end to the assessment process.

c. The nurse chooses treatment that will positively affect the patient's care.

d. The nurse has difficulty accepting the patient's self-report as valid.

D. The nurse has difficulty accepting the patient's self-report as valid.

Rationale: Nurses approach patient care with the influences of their education, cultural background, and family values. As much as they try to be open-minded and nonjudgmental, personal prejudices and biases can affect how nurses perceive the patient's self-report of pain. Nurses still have difficulty accepting the patient's report of pain as valid and credible.

The nurse is admitting a 75-year-old male with a 50-year history of smoking one pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is

a. pitting.

b. thickening and discoloration of the nail bed.

c. clubbing.

d. brittleness and cracking of the nails.

C. Clubbing.

Rationale: Chronic hypoxia decreases oxygenation of the distal extremities. Associated clubbing changes will be evident.

All of the following skin lesions may be papular except

a. warts.

b. acne.

c. nevi.

d. herpes zoster.

D. Herpes zoster.

Rationale: The lesions of herpes zoster are vesicular, warts and nevi or moles are benign papules, and acne lesions include papules as well as pustules.

When assessing hydration, the nurse will

a. pinch a fold of skin on the medial aspect of the forearm and observe for recoil to normal.

b. pinch a fold of skin on the abdomen and observe for recoil to normal.

c. pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal.

d. pinch a fold of skin on the head and allow for skin to recoil in children.

C. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal.

Rationale: To assess turgor in an adult, the most reliable method is to pinch a fold of skin on the anterior chest, release, and observe for the skin to promptly recoil to its original state.

A fair-skinned, blonde, 18-year-old female is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching? (Select all that apply.)

a. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer.

b. Apply a sunscreen or sunblock at least 15 to 30 minutes before sun exposure.

c. Avoid sun exposure between 10 a.m. and 4 p.m. to reduce UVA and UVB exposure.

d. A mild sunburn is acceptable in a fair-skinned blonde person.

A, B, C. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer, apply a sunscreen or sunblock at least 15 to 30 minutes before sun exposure, and avoid sun exposure between 10 a.m. and 4 p.m. to reduce UVA and UVB exposure.

Rationale: Teaching the patient about the harmful effects of UVA and UVB exposure will help her understand the importance of sun protection. Sunscreens or sunblocks applied in time for the skin to fully absorb them afford the best protection. Avoiding the sun during the midday decreases exposure to intense and harmful UVA and UVB rays.

A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. Which of the following infectious illnesses does the nurse suspect?

a. Varicella

b. Measles

c. Roseola

d. Herpes simplex

A. Varicella.

Rationale: Varicella (chicken pox) is a highly contagious infectious disease. It occurs most frequently in children. It is characterized by single to multiple erythematous vesicles anywhere on the body. As the disease progresses, the vesicles progress into shallow ulcers covered with scabs. Measles is a rash of macules and papules. Herpes simplex is generally localized to one area of the body and consists of grouped vesicles on an erythematous base. Roseola is a macular and papular rash.

A 24-year-old patient reports an itchy red rash under their breasts/chest. Examination reveals large, reddened, moist patches under both breasts/chest in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions?

a. Satellite

b. Discrete

c. Confluent

d. Zosteriform

A. Satellite.

Rationale: Single lesions in close proximity to a larger lesion are termed satellite lesions. Discrete distribution identifies lesions that are totally separate from one another. Confluent lesions are several lesions that have merged together, and zosteriform distribution identifies lesions, which follow a dermatomal pathway.

A 22-year-old patient presents to the clinic with a large firm mass on their left earlobe. They had their ears pierced approximately 6 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in.) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion?

a. Crust

b. Lichenification

c. Keloid

d. Scale

C. Keloid.

Rationale: Keloid is an excessive accumulation of fibrin tissue in response to wound healing. Lichenifications are exaggerated skin lines as a result of chronic irritation or scratching. Crust is a dried secretion from a primary lesion, and a scale results from excessive proliferation of the upper epidermal skin layers without normal shedding of dead cells.

An 83-year-old female is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation?

a. Thinning of the skin

b. Increased skin turgor

c. Hypopigmented flat macules and patches over sun-exposed areas

d. Multiple purplish bruises on the arms and legs

A. Thinning of the skin.

Rationale: The skin layers thin with aging, resulting in decreased skin turgor. Thinned skin is subject to increased trauma from shearing or friction, which increases the risk for purpuric lesions. Nevertheless, such lesions are not a normal variant of aging skin. Hyperpigmented macules and papules (commonly seborrheic keratoses) are present on sun-damaged skin.

A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion?

a. Papule

b. Pustule

c. Cyst

d. Vesicle

B. Pustule.

Rationale: Pustules are palpable erythematous lesions containing pus or other infectious material. Papules are solid. Cysts can contain serous as well as infectious substances and extend into the deeper layers of skin. Vesicles are small, thin-roofed lesions containing clear serous fluid.

While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next?

a. Document this finding as normal.

b. Tell the patient that this finding is unexpected.

c. Report this finding to the healthcare provider.

d. Look for signs of hypothyroidism.

A. Document this finding as normal.

Rationale: The thyroid gland is often not palpable. With no signs or symptoms of hypothyroidism or hyperthyroidism, a nonpalpable thyroid would be a normal finding.

While examining the patient's lymph nodes, the nurse finds enlarged nodes located in front of the mastoid bone. The nurse documents enlargement of which nodes?

a. Preauricular nodes

b. Occipital nodes

c. Superficial cervical nodes

d. Supraclavicular nodes

A. Preauricular nodes.

Rationale: The preauricular are, as the name implies, in front of (or pre-) the ear (auricle). Occipital nodes are at the base of the skull posteriorly. Cervical nodes are in the neck, and supraclavicular are above the clavicle.

A 40-year-old female presents with symptoms of hypothyroidism. What signs and symptoms are most consistent with a patient who has hypothyroidism?

a. Slightly obese, perspiring female, who complains of feeling cold all the time and having diarrhea

b. Slightly obese female with periorbital edema, who complains of cold intolerance, brittle hair, and dry skin

c. Thin, anxious-appearing female with exophthalmos and a rapid pulse and who complains of diarrhea

d. Thin, perspiring female with a deep hoarse voice, facial edema, a thick tongue, and reports of diarrhea

B. Slightly obese female with periorbital edema, who complains of cold intolerance, brittle hair, and dry skin.

Rationale: The patient with hypothyroidism would likely demonstrate clinical signs and symptoms of a low metabolic rate resulting from relative depletion of circulating thyroid hormone.

Physical examination of a patient reveals an enlarged tender tonsillar lymph node. What action would the nurse take next?

a. Assess for meningitis.

b. Assess for dietary changes.

c. Assess for an infection upstream.

d. Assess for enlarged nodes in other regions.

C. Assess for an infection upstream.

Rationale: Infected lymph nodes are usually tender. Fixed, hard, or irregular nodes should be further evaluated as a sign of possible cancer.

The nurse is teaching an 18-year-old female, who does not use tobacco or consume alcohol, health promotion related to the head and neck. The nurse includes teaching about which of the following? (Select all that apply.)

a. Seatbelt use

b. Refraining from texting while driving

c. Wearing a helmet

d. Cancers of the neck

A, B, C. Seatbelt use, refraining from texting while driving, and wearing a helmet.

Rationale: Health promotion includes activities to maintain health and safety. Not texting while driving and the use of seatbelts and helmets maintain safety.

While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action?

a. Recognize that it is not common to palpate lymph nodes in this region and that they must be carefully evaluated.

b. Recognize that enlarged lymph nodes in this area indicate sinus inflammation.

c. Recognize that this is a common area for lymph nodes to be enlarged with minor infections.

d. Recognize that a palpable lymph node in this region is always indicative of malignancy.

A. Recognize that it is not common to palpate lymph nodes in this region and that they must be carefully evaluated.

Rationale: Cancers of the lung, breasts/chest, and abdomen may metastasize to the lymph nodes and be first accessible during clinical assessment in the supraclavicular region.

A patient presents with a complaint of drooping of the eyelid on one side. This finding is documented as which of the following?

a. Kernig sign

b. Pharyngitis

c. Thyroglossal cyst

d. Ptosis

D. Ptosis.

Rationale: Kernig sign is found with meningitis. Pharyngitis is inflamed and sore throat. A thyroglossal cyst is a birth defect mass found in the neck.

Which of the following is part of the upper gastrointestinal tract?

a. Nasal septum

b. Sinuses

c. Throat

d. Adenoids

C. Throat.

Rationale: The throat is part of the upper gastrointestinal tract. The nasal septum, sinuses, and adenoids are parts of the upper respiratory tract.

The nurse is assessing the nares to evaluate the site of epistaxis. The most common site of bleeding is which of the following?

a. Ostiomeatal complex

b. Nasal septum

c. Kiesselbach plexus

d. Woodruff plexus

C. Kiesselbach plexus.

Rationale: Kiesselbach plexus is a highly vascular area of the nose and a common site for bleeding. The ostiomeatal complex and nasal septum are other parts of the nose.

The nurse knows that the floor of the mouth is highly vascular and therefore a good location for which of the following?

a. Absorption of sublingual medications

b. Identification of malignancy in the pharyngeal fossa

c. Infection with streptococcus

d. Aspiration, even if the gag reflex is present

A. Absorption of sublingual medications.

Rationale: The sublingual palate is a good location for taking oral temperatures and for the absorption of sublingual medications. It is very thin walled compared to the other areas.

Risk factors for nose, sinus, mouth, and throat problems include

a. topical decongestant use, smoking, and allergies.

b. smoking, allergies, and high blood cholesterol.

c. allergies, high blood cholesterol, and topical decongestant use.

d. high blood cholesterol, topical decongestant use, and smoking.

A. Topical decongestant use, smoking, and allergies.

Rationale: Risk factors specific to this area include topical decongestant use, smoking, inhaling substances and chemicals, allergies, and dust exposure. High blood cholesterol affects circulation and can cause stroke, heart attack, and macrovascular complications.

The nurse has assessed the nose and documents expected findings as

a. nose asymmetrical with clear drainage.

b. nose symmetrical and midline.

c. nose asymmetrical and proportional to facial features.

d. nose symmetrical with yellow drainage.

B. Nose symmetrical and midline.

Rationale: Normal documentation of the assessment of the nose would include findings such as symmetrical, midline, without drainage, and proportional to facial features. An asymmetrical nose is found with a deviated septum, and yellow drainage is found with infection.

The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral assessment is important because of the increased risk for which of the following?

a. Fordyce granules

b. Pharyngitis

c. Anosmia

d. Candida albicans

D. Candida albicans.

Rationale: Antibiotics alter the normal flora of the mouth and may cause overgrowth of the yeast that exists in the mouth, which is C. albicans. Fordyce granules are found with infants, pharyngitis is associated with infection and inflammation, and anosmia is noted with COVID-19.

An adolescent male presents with complaints of nosebleeds. The nurse would further assess for

a. hemangioma.

b. nasal trauma.

c. angiofibroma.

d. cystic fibrosis.

B. Nasal trauma.

Rationale: Nasal trauma is the most common cause of epistaxis in adolescents. Cystic fibrosis has an effect on the neurological system. Hemangiomas are benign tumors of the blood vessels that cause a birthmark. Fibroadenomas are a benign growth commonly in the breast/chest.

The nurse assesses the child with purulent, unilateral nasal discharge. The nurse knows that the most likely causative factor is

a. allergic rhinitis.

b. choanal atresia.

c. foreign body in nose.

d. cystic fibrosis.

C. Foreign body in nose.

Rationale: The foreign body causes discharge; the most significant finding is that the drainage is unilateral. Most other processes involve both nares.

During routine physical examination of a 20-year-old female, the nurse notes a septal perforation. This finding may be significant for which of the following causes?

a. Illicit drug use

b. Nose picking

c. Nasal trauma

d. Bifid uvula

A. Illicit drug use.

Rationale: Cocaine and inhaled substances irritate the nose and may cause perforation. The vasoconstriction from the substance causes the thin mucosa to erode and even penetrate through the entire septum.

The patient with a head injury and increasing ICP is likely to have which assessment findings?

a. Decreased LOC and sluggish pupil

b. Left-sided weakness and facial droop

c. Right ptosis and right-sided loss of vision

d. Dilated left pupil and receptive aphasia

A. Decreased LOC and sluggish pupil.

Rationale: Because increasing intracranial pressure is a global process, the findings are more general and less specific. Findings localized to the left or right side are more commonly associated with specific areas of the brain, as with a stroke.

The chart states that a 62-year-old person has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following?

a. Tremors on the left side of the face

b. Tremors on the right side of the face

c. Weakness in the right arm

d. Weakness in the left arm

D. Weakness in the left arm.

Rationale: Weakness results from loss of motor function in the motor cortex of the brain. Tremors are associated with other diseases (e.g., Parkinson disease and multiple sclerosis). The deficit is on the opposite side of the body because the motor fibers cross, causing left-sided weakness.

The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke:

a. Low BP, lack of exercise, and diet high in fat

b. High BP, diet high in fat, and smoking

c. Diet high in fat, smoking, and walking five times weekly

d. Obesity, swimming five times weekly, high BP

B. High BP, diet high in fat, and smoking.

Rationale: A health history of diabetes mellitus, carotid artery disease, atrial fibrillation, and sickle cell disease places a person at risk for neurovascular disease. Additionally, the lifestyle choices of smoking, high-fat diet, obesity, and physical inactivity increase the person's risk for stroke.

If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following?

a. Hyporeflexia

b. Normal plantar reflex

c. Cushing response

d. Babinski sign

D. Babinski sign.

Rationale: The Babinski sign indicates pathological hyperreflexia. A normal plantar reflex would result in toes curling downward to the same stimulus. The Cushing response refers to a pattern of changes in vital signs, not reflexes.

A 26-year-old person was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the:

a. legs.

b. abdomen.

c. chest.

d. arms.

A. Legs.

Rationale: The level of injury in the spinal cord correlates with innervation on the skin according to the level of the dermatome. Innervation of the arm roughly correlates with C5 to T1. Innervation of the chest correlates with T1 to T8. Innervation of the abdomen corresponds to T9 to T12. Innervation of the legs corresponds to L1 to S1.

A patient in a nursing home was admitted with a diagnosis of dementia. They started a fire because they were cooking at home and forgot that they left a pan on the stove. The nursing diagnosis that is of highest priority is:

a. ineffective brain tissue perfusion.

b. risk for injury.

c. acute confusion.

d. impaired memory.

B. Risk for injury.

Rationale: Safety assumes priority because of the risk for injury. Impaired memory is also a likely diagnosis because of his forgetfulness. No data exist about confusion, so that is an area that needs further assessment. Ineffective brain perfusion is associated more with a stroke.

A 47-year-old patient states they are having vertigo and some difficulty with balance. The nurse should assess:

a. accommodation.

b. the whisper test.

c. shoulder strength.

d. soft touch.

B. The whisper test.

Rationale: Balance and equilibrium are associated with CN VIII. Performing a whisper test will evaluate hearing, also associated with CN VIII. Testing for accommodation evaluates CN III. Shoulder shrug assesses CN XI and soft touch assesses CN V.

Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemispheres?

a. An enlarging pupil that is sluggishly reactive to light

b. Altered mentation

c. Widening pulse pressure with bradycardia

d. Reflex posturing of extremities

B. Altered mentation.

Rationale: Mental status changes are the earliest (often initially subtle) indications of generalized hemispheric dysfunction and occur prior to the cranial nerve or brainstem compression required to produce the other listed signs.

Which of the following statements describes the cardiovascular system most accurately?

a. It is a double pump circulating blood out to the lungs and body.

b. It has a heart with six chambers, great vessels, and valves.

c. It includes concepts of pre-contractility, post-contractility, and load.

d. It functions with a conduction system that starts in the ventricles.

A. It is a double pump circulating blood out to the lungs and body.

Rationale: The heart is a double pump with four chambers, four valves, and a conduction system that has a pacemaker originating in the atrium (SA node). The right side of the heart pumps to the lungs and the left side of the heart pumps to the head and the body. Concepts of preload, afterload, and contractility are used when considering the effectiveness of the pumping.

When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is

a. S1 greater than S2.

b. S1 is equal to S2.

c. S2 greater than S1.

d. no S1 is heard.

A. S1 greater than S2.

Rationale: Closure of the mitral and tricuspid valves at the beginning of systole produces the S1. This closure prevents backflow of blood from the ventricles into the atria. S1 is loudest over these valves, located in the 5th left ICS at the sternal border (tricuspid) and the 5th left ICS at the MCL (mitral).

The nurse assesses the neck vessels in the stable patient with heart failure to determine which of the following?

a. The bilateral carotid pulse

b. The presence of bruits

c. The highest level of jugular venous pulsation

d. The strength of the jugular veins

C. The highest level of jugular venous pulsation.

Rationale: The nurse looks for fluid volume overload in the patient with congestive heart failure (CHF). An elevated jugular venous pulsation reflects fluid volume overload in the right heart. The bilateral carotid pulse is never palpated, because doing so may obstruct the circulation to the brain and cause the patient to faint. Bruits are auscultated in the carotids for the presence of narrowing that may lead to stroke; the carotids, not the jugular veins, are also palpated for arterial pulse strength.

The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority?

a. Auscultate heart sounds.

b. Inspect the precordium.

c. Percuss the left border.

d. Obtain pulse and BP.

D. Obtain pulse and BP.

Rationale: BP serves as an indicator of hemodynamic stability in this acute situation. Evaluating the pulse and BP indicates if the patient has an effective pulse. Although heart sounds will be auscultated, the highest priority is identifying the consequences of chest pain and cardiac ischemia. Abnormal heart sounds may or may not reflect ischemia.

A patient who visits the clinic has the controllable risk factors of smoking, high-fat diet, overweight, decreased activity, and high BP. What concept should the nurse use when performing patient teaching?

a. Teach the patient the most serious information.

b. Give the patient brochures to review before the next visit.

c. Discuss risk factors that the patient is interested in modifying.

d. Describe consequences of risk factors to motivate the patient.

C. Discuss risk factors that the patient is interested in modifying.

Rationale: Because multiple risk factors are apparent, the most effective strategy may be for the patient to identify those items that they would like to change. Presentation of many brochures is likely to overwhelm the patient; it is better to focus attention on one or two things that the patient is interested in modifying.

Which of the following clusters of symptoms are common in females preceding an MI?

a. Chest pain, nausea, diaphoresis

b. Weight gain, edema, nocturia

c. Dizziness, palpitations, low pulse

d. Fatigue, difficulty sleeping, dyspnea

D. Fatigue, difficulty sleeping, dyspnea.

Rationale: Men typically have chest pain, nausea, and diaphoresis. Weight gain, edema, and nocturia are typical symptoms of CHF. Dizziness, palpitations, and low pulse are common with arrhythmias. Fatigue is a common presenting symptom in women.

The nurse auscultates a medium-loud whooshing sound that softens between S1 and S2. The nurse documents this finding as which of the following?

a. Grade III systolic murmur

b. Grade I systolic murmur

c. Grade V diastolic murmur

d. Grade II diastolic murmur

A. Grade III systolic murmur.

Rationale: A medium loud murmur is graded III or IV on a I to VI scale. Murmurs between S1 and S2 are systolic; those between S2 and S1 are diastolic.

A patient is having adverse effects resulting from a medication. The nurse calls the primary care provider to request a change in the medication order. The nurse is functioning as a(n)

a) educator.

b) advocate.

c) organizer.

d) counselor.

B. Advocate.

Rationale: By voicing concerns about the patient, the nurse functions as an advocate to improve the quality of care.

Nurses advocate for underserved populations to reduce health disparities. This promotes

a) autonomy.

b) altruism.

c) respect.

d) human dignity.

C. Respect.

Rationale: Nurses promote respect and social justice when they treat individuals, families, and communities to improve the disparities present in the healthcare system.

Nurses belong to the ANA as part of their

a) ongoing professional responsibility.

b) role as manager of care.

c) wellness promotion for patients.

d) cultural education activities.

A. Ongoing professional responsibility.

Rationale: Nurses continually learn and promote health as part of their ongoing professional responsibility.

The purpose of health assessment is to

a) obtain subjective and objective data.

b) intervene to correct difficulties.

c) outline appropriate care.

d) determine whether interventions are effective.

A. Obtain subjective and objective data.

Rationale: Health assessment is the method by which nurses gather subjective and objective data.

The nurse provides teaching about smoking cessation to a 20-year-old patient. The nurse assesses that the patient is concerned because their father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient?

a) Health belief model

b) Diagnostic reasoning model

c) Cultural competence model

d) Body systems model

A. Health belief model.

Rationale: The nurse will use the health belief model to assess the patient's perspective about the relationship between smoking and lung disease. The nurse must assess the patient's family experience. They may have some personal beliefs that influence their motivation to stop smoking.

Which of the following processes is the most important when providing nursing care to a patient who is ill?

a) Writing outcomes

b) Performing a focused assessment

c) Collecting objective data

d) Using clinical judgment.

D. Using clinical judgment.

Rationale: Assessment provides a solid foundation for care, but it is only one step in the nursing process. Clinical judgment is used in all phases of the nursing process.

A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform on admission?

a) Emergency

b) Focused

c) Comprehensive

d) Illness

C. Comprehensive.

Rationale: Surgery involves all body systems, so it is important to perform a comprehensive assessment.

Which of the following are the components of a comprehensive health assessment?

a) Nursing diagnoses

b) Goals and outcomes

c) Collaborative problems

d) Examination of body systems

D. Examination of body systems.

Rationale: In a comprehensive assessment, the nurse collects subjective and objective data, including a history of the current problem, medical history, and common symptoms and a head-to-toe physical examination.

The nurse conducts the health history based on the patient's responses to the medical diagnosis. This type of framework is based on the

a) functional framework.

b) objective framework.

c) coordinator framework.

d) collaborative framework.

A. Functional framework.

Rationale: It is based on the functional framework. In the medical model, the provider evaluates the medical diagnosis, such as myocardial infarction. The provider may order some diagnostic tests to evaluate the extent of damage. The nurse assesses the patient's response to the myocardial infarction, such as fluid retention or arrhythmias. In addition, the nurse assesses functional abilities, such as coping, role performance, and activity tolerance.

The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to

a) role.

b) self-perception.

c) coping.

d) values.

D. Values.

Rationale: Values address important big concepts of life and death. Role addresses the daily duties or tasks. Assessment of self-perception focuses on how the patient thinks about themself. Coping is in response to a stressor.

The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking is assessing

a) whether the patient is a reliable historian.

b) functional health patterns.

c) ADLs.

d) review of systems.

C. ADLs.

Rationale: Activities of daily living (ADLs) are those things that a person needs to accomplish each day to care for the self.

Which of the following is an appropriate use of gloves?

a. Gloves are worn during anticipated contact with intact skin.

b. Gloves are removed when going from clean to contaminated areas.

c. Gloves are worn during anticipated contact with body secretions.

d. Gloves are removed when assessing the back of an incontinent patient.

C. Gloves are worn during anticipated contact with body secretions.

Rationale: Healthcare providers should wear gloves to prevent exposure when they are at risk for coming into contact with body secretions of patients. The gloves protect patients by preventing nurses from transmitting infections from contaminated to cleaner areas. Generally, the area around the bed or examination table is considered most contaminated, whereas supply cupboards and computers are considered clean. Gloves should never be worn from the room into the hall.

Which of the following are advantages of the electronic medical record? (Select all that apply.)

a. Nurses can enter data by checking boxes and adding free full text.

b. It is economical and easy to learn and implement.

c. It allows primary care providers to directly order into the computer.

d. It cannot be used as a legal document in case of a lawsuit.

A, C. Nurses can enter data by checking boxes and adding free full text and it allows primary care providers to directly order into the computer.

Rationale: Computerization ensures that all entries are legible and time dated; it also ensures a more complete assessment because programs will not let nurses enter data until they have completed all required fields. CPOE allows providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing unit. Implementing a computerized system is expensive and requires much planning and education. Although there is no hard copy, the electronic medication administration record is still considered the legal record.

In the SBAR reporting format, which of the following would be an example of data found in the assessment?

a. Mrs. Kelly's diagnosis is Stage II breast cancer.

b. Mr. Imami's lung sounds are decreased.

c. Ms. Choi needs to have a social work consult.

d. Mr. Jones was admitted at 10:30 this morning.

B. Mr. Imami's lung sounds are decreased.

Rationale: Assessment findings are subjective or objective data. Stage II cancer is assessment or analysis, social work consult is recommendation, and admission at 10:30 is situation.

The patient's radial pulse is weak and thready. The next action of the nurse is to

a. transfer the patient to a critical care unit.

b. notify the primary care provider.

c. compare findings with previous findings and opposite extremity.

d. assess vital signs every 15 minutes.

C. Compare findings with previous findings and opposite extremity.

Rationale: The popliteal pulse is often difficult to palpate. Comparing with previous findings and with the opposite extremity can help determine if any acute changes have occurred.