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HEALTH ASSESSMENT PROCTORED EXAM
Total Questions : 47
Showing 10 questions, Sign in for morefindings align with the ABCDE rule and should be reported to the healthcare provider? Select all that apply.
A nurse is reviewing the charts of four patients. Which patient requires the most immediate intervention related to skin changes?
The nurse is percussing the patient's abdomen. Which percussion tone should be heard over the liver?
The nurse assesses a patient's neurologic function. Which sign could indicate injury to the cerebellum? Select all that apply.
The nurse is assessing a patient's active range of motion (ROM) and notices limited extension at the left elbow. What is the next step for the nurse to take?
A patient reports severe abdominal pain around the umbilicus and right lower quadrant (RLQ) as well as nausea and vomiting for 2 days. Place these nursing assessment steps in the correct order.
Explanation
D. Handwashing: This is the initial step to ensure infection control and prevent the transmission of nosocomial pathogens. It must precede any physical contact with the patient's integument or environment. Maintaining aseptic technique is fundamental to all nursing physical examination protocols.
C. Inspecting for position: Inspection provides visual data on patient distress or abdominal contour without disturbing the viscera. This non-invasive step allows the nurse to observe for signs of peritonitis, such as lying perfectly still. It must be performed before any manual manipulation of the abdomen.
F. Auscultating for bowel sounds: Auscultation follows inspection to ensure that bowel sounds are not artificially altered by manual manipulation or palpation. This sequence prevents the elicitation of false hyperactive or hypoactive sounds. It provides a baseline for peristaltic activity before the abdomen is touched.
E. Palpating lightly: Light palpation identifies areas of muscular guarding and superficial masses while minimizing patient discomfort. This step precedes deep palpation to prevent premature elicitation of severe pain. It helps localize the area of maximal tenderness mentioned in the clinical presentation.
B. Palpating for rebound tenderness: Deep palpation for rebound tenderness is performed last because it often causes significant pain and distress. This is a specific assessment for peritoneal irritation often seen in clinical cases of appendicitis. It provides the final physical evidence of an acute abdominal process.
A. Notifying the health care provider: Communication of findings to the physician is the final step after a comprehensive assessment is documented. This allows the nurse to provide a complete clinical picture, including vital signs and specific abdominal findings. Timely reporting facilitates urgent surgical or medical intervention.
The nurse is assessing a newborn with a scaphoid abdomen. Which condition is likely to cause the problem?
Which of the following is common when a patient's nutritional reserves are depleted? Select all that apply.
A nurse is caring for a newborn diagnosed with erythema toxicum neonatorum. Which nursing action is most appropriate?
What is a dermatome?
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