The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?
Appearance and behavior
The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include?
Place the back of your hand against the child's forehead and then on the back of the neck
While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider?
Pain reported when palpating posterior lower thorax
The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include?
Oral contraceptives and anti-inflammatories make the skin more sensitive to the sun.
As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.)
Applying adhesive tape to anchor a nasogastric tube; Inserting a rubber Foley catheter into the patient's bladder; Giving an injection using plastic syringes with rubbercoated plungers
The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up?
Palpation of a right dorsalis pedis pulse with strength of +1
The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient's reported symptoms related to upper respiratory infection?
Retropharyngeal lymph nodes are enlarged and firm
The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.)
A normal pulse on the top of the foot indicates adequate blood flow to the foot; Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?
Supine with the right arm abducted and hand under the head and neck
The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include?
The aorta can be felt using deep palpation in the upper abdomen near the midline.
The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct?
The testes are normally round and feel smooth and rubbery
The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding?
Patient's abduction of right arm was limited to 100 degrees.
The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform?
What does this mean: 'A stitch in time saves nine? '
The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient?
VII � Facial
The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.)
Inspect the lips and mucous membranes to determine if they are moist; Check the patient's pulse and blood pressure; Weigh the patient daily