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NURS 100 Assessment 2. WCU Exam Questions And Answers 2024 Series
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NURS 100 Assessment 2. WCU Exam Questions AndAnswers 2024 Series
Objective data can be gathered about the patient through which of the following
components of the physical exam? (Select all that apply.) a. Patient interview b. Health
history c. General survey d. Physical examination e. Laboratory testing
Objective data refers to observed information or signs that can be collected throughout
all the steps of the physical examination process. Even while the patient is answering
questions and the nurse is collecting subjective or symptomatic data, the nurse observes
for physical manifestations of dysfunction or impairment.
Which of the following sequences is the correct order in which the nurse should perform
an abdominal examination?
a. Inspection, palpation, percussion, auscultation
b. Auscultation, inspection, palpation, percussion
c. Auscultation, palpation, percussion, inspection
d. Inspection, auscultation, percussion, palpation
Assessment of the abdominal cavity needs to be done in the order of inspection then
auscultation, percussion then palpation to prevent sending stimuli through the bowel and
eliciting false assessment findings.
A nurse is going to auscultate a patient's chest. While assessing this patient's aortic
valve, where should the nurse listen?
a. Second right intercostal space
b. Third left intercostal space
,c. Fifth right intercostal space
d. Fifth left intercostal space along the midclavicular line - Answer a. Second right
intercostal space
Explanation: The second intercostal space to the right is the auscultation point for the
aortic valve. Ventricles and pulmonic valve are on the left. The PMI over the mitral valve is
between the left fourth and fifth intercostal spaces.
The nurse examines the eyes of an adult client and notices an abnormal drooping of one
eyelid. Which of the following etiological possibilities would be the most worrisome,
requiring follow-up as soon as possible?
a. Loss of skin elasticity
b. Levator muscle weakness
c. Congenital ocular abnormality
d. Oculomotor cranial nerve III paralysis - Answer d. Oculomotor cranial nerve III
paralysis
Oculomotor paralysis may be indicative of a greater neurologic concern that needs to be
investigated further and as soon as possible. Loss of elasticity in the skin and muscle
weakness are benign and due to aging; therefore, congenital ptosis is not a condition of
concern for an adult immediately.
What type of breath sounds would the nurse expect to hear over most of the lung fields?
a. Vesicular
b. Resonant
c. Dull
d. Flat - Answer a. Vesicular
Vesicular breathe sound are heard over most of the lung fields. Resonance is heard with
,percussion, not auscultation. Dullness is heard over the solid organs (liver, heart). Flat
sounds are heard over the stomach and intestines.
When teaching a patient about fire safety, which activity does the nurse know is the
leading cause of fire-related death?
a. Cooking
b. Playing with matches
c. Smoking
d. Heating with kerosene heaters - Answer a. Cooking
Cooking I the leading cause of residential fires for the last decade, followed by heating,
electrical malfunction. And other unintentional causes or carelessness.
Wilcox-McCombs et al. 2005
Which measures can the nurse teach to prevent poisoning of children? (Select all that
apply.)
a. Install safety latches on reachable cabinets.
b. Keep syrup of ipecac on hand.
c. Use childproof caps on medications.
d. Use a plunger rather than a chemical drain cleaner.
e. Put all cleaning supplies under the cabinet in the kitchen sink. -Answer a. Place safety
latches on lower cabinets that are accessible.
c. Use childproof caps for medications.
d. Use plunger instead of chemical cleaner for unclogging drains.
Putting child locks on cabinets and childproof caps on medication bottles can help.
Using alternative substances such as plungers instead of using poisonous chemicals,
such as Drano, to unclog drains may also be utilized as a precaution. Syrup of ipecac has
been used to treat poisoning after the fact and is therefore not a prevention method.
Under the kitchen sink is not a good place to store cleaning supplies because the area is
within reach of children.
, Which of the following restraint-free alternatives is best for the nurse to use for an
84-year-old confused, incontinent patient after hip replacement?
a. Room near the nurses' station and decreased sensory stimuli
b. Pressure sensor alarm and room near the nurses' station
c. Side rails up and decreased sensory stimuli
d. A 24-hour sitter and the patient's favorite TV program - Answer b. A pressure sensor
alarm and a room near the nurses' station
The confused patient may not recall calling for assistance prior to rising if they
experience an episode of incontinence. Implement a pressure sensor alarm that can be
used in a bed or chair as a priority intervention, along with moving the patient to a room
near the nurse's station where the patient can be more closely monitored. Decreasing
sensory stimuli may be helpful for the patient who is confused but it is not a priority
intervention. A 24-hour sitter is expensive and utilized only after all other restraint free
alternative have been used.
Which of the following is the most appropriate activity for the RN to delegate to the UAP?
a. The patient's fall risk and complications of restraint use
b. The patient's ability to perform his ADLs
c. Assisting with or performing the patient's ADLs
d. Teaching the use of assistive devices - Answer c. Assisting with or performing the
patient's ADLs
UAP's, for example, patient care technicians and nursing assistants, provide direct care
to patients that require full care or total assistance with their ADL's. However, RN's are
responsible for monitoring and directing the UAP to ensure that direct care provided is in
a safe manner. RNs deliver detailed patients assessments and the OT assesses the
patient ability to carry out ADL's. A physical therapist evaluates mobility and initially
teaches the patient to use an assistive device. If use assistive device needs
reinforcement, the RN does the teaching.
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