NR 302 Exam 1 Study
***NOTE: Read about hypertension stages***
A patient's weekly blood pressure readings have ranged between 124/84 and 136/88, with an
average reading of 126/86. Which catagory of blood pressure does this fall into?
1). Prehypertension
2). Stage 1 hypertension
3). Stage 2 hypertension - ANS-1
A 2-year old child has been brought to your clinic for a well-child checkup. The best way for the
nurse to begin the assessment is to:
A). Ask the parent to place the child on the exam table
B). Have the parent remove all the child's clothing prior to the examination.
C). Allow the child to keep a security object such as a blanket or a teddy bear during the
examination.
D). Initially focus the interactions on the child and ignore the parent until the child's trust has
been obtained. - ANS-C
A man is in the clinic for an examination. He states that he is "very anxious" about the physical
examination. What steps can the nurse take to make him more comfortable?
A). Appear unhurried and confident when examining him
B). Stay in the room when he undresses in case he needs assistance.
C). Ask him to change into a gown and change out of his undergarments
D). Defer measuring VS until the end of the examination - ANS-A: Appear unhurried and
confident when examining him
A nurse is performing an assessment of the ABDOMINAL region. What is the appropriate
sequence for examination?
1). Palpation, percussion, inspection, auscultation.
2). Inspection, palpitation, auscultation, percussion.
3). Auscultation, percussion, inspection, palptation
4). Inspection, ascultation, percussion, palpation - ANS-4
A patient has suddenly developed SOB and appears to be in significant respiratory distress.
After calling the MD and placing the patient on O2, which of these actions is best for the nurse
to take when assessing the patient?
1). Count the patient's respirations
2). Bilaterally percuss the thorax, noting any differences in percussion tones.
3). Call for CXR and wait for results before assessing
4). Inspect the throax for any new masses or bleeding that would interfere with respirations. -
ANS-2). Bilaterally percuss the thorax, noting any differences in percussion tones.
, An examiner is using an ophthalmoscope to examine a patients eyes. The patient has
astigmatism and is nearsighted. The use of which of these techniques would indicate that the
examination is being done correctly?
A). Using the large full circle of light when assessing pupils that are not dilated.
B). Rotating the lense selector to the black numbers to compensate for astigmatism.
C). Using the grid on the lens aperture dial to visualize the soft structures of the eye.
D). Rotating the lens selector dial to bring the object into focus. - ANS-D
Before auscultating the abdoment for the presence of bowel sounds, the nurse should:
A). Warm the endpiece of the stethoscope by placing it in warm water.
B). Leave the gown on the patient during the examination so the patient does not get chilled.
C). Ensure the bell side of the stethoscope is turned "on"
D). Check the temp of the room and offer blankets as needed if the patient feels cold. - ANS-D:
Check the temp of the room and offer blankets as needed if the patient feels cold.
During an examination of the patients abdomen, the nurse notes that the abdomen is round and
firm to the touch. During percussion, the nurse notes a drumlike quality of sounds across the
quadrant. This type of sound indicates:
A). constipation
B). air-filled areas
C). presence of a tumor
D). presence of dense organs - ANS-B
During palpation, the dorsa of the hand/fingers is suggested as the best site for assessing what
type of clinical manifestations? - ANS-Temperature
During palpitation, your fingertips are best used to seek out what types of findings? - ANS-Skin
texture, swelling, pulsation, presence of lumps/masses.
"Fine tactile discrimination"
Explain "cultural and linguistic competence" - ANS-Congruent behaviors, attitudes, and policies
that come together in a system among professionals that enables wor in cross-cultural
situations.
Explain "effective care": - ANS-Positive outcomes and satisfaction for the patient.
Explain "respectful care" - ANS-Considers values, preferences, and expressed needs of patient.
Explain dull sounds and where they may be heard when percussing? - ANS--Amplitude: soft
-Pitch: high
-Quality: muffled thud
-Duration: short
-Found commonly over relatively dense organs such as the liver or spleen
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