Nursing Assessment

How should testicles feel?

Rubbery, smooth

What would be an appropriate score for a health adult on the MMSE ?

22-31 (in book)
25-30 (handout)

A nurse is teaching a patient how to conduct a self breast examination. Which of the following indicates good understanding of the technique.

Up and Down/Vertical

What are the 3 things the Glasgow coma scale measures? Select all that apply

Verbal response
Eye response
Motor response

A nurse is assessing a patients hair and scalp. Which of the following would be considerations
made by the nurse, or what they should ask the patient? Select all that apply

hair care products
wigs
hair loss
diet
vasodilators
chemotherapy

A patient reports experiencing pain radiating from his elbow to his hand. Which of the following
are appropriate nursing actions? (SATA)

Ask about the pain

Which of the following are concerns about a patient's nutritional status (SATA)

Religious beliefs
Inability to swallow
Food allergies
Sudden change in taste
Weight loss/Weight gain recently

Which of the following are things we assess when we assess gait? (SATA)

Speed and rhythm
Turning ?safety?

Location of mitral valve

5th intercostal space left mid clavicular line

Location tricuspid valve

4-5th intercostal space left of the sternum

Best order for listening lung sounds

6 sites listed

It asked about reflexes- what you would expect if you hit a patellar deep tendon reflex

2+ and extension of the leg

It asked about neurological assessment

Perrla
MMSE and other things
Appropriate emotions etc

What would be expected findings of the structures on the neck?

Symmetrical muscles
Non-Palpable lymph nodes
Trachea midline

What would be the expected finding of a palpable lymph node?

Non-tender

A nurse is teaching a patient how to conduct a self-teste exam. What is a true statement regarding teste sensitivity?

Testes should be sensitive but not tender

There was a question about understanding timelines of prostate cancer

For men ages 50+, digital rectal examination (DRE) and prostate-specific antigen test (PSA).

The question regarding a patient understanding what they need to do at 50 (book says 45+) pg 546 years old for colorectal cancer

Fecal occult test Box.30.28
Flexible sigmoidoscopy (FSIG):
Double-contrast barium enema every 5 years if
recommended by health care provider
Colonoscopy every 10 years if recommended
Computed tomography (CT) colonoscopy every 5 years
if recommended

What is the first question you should ask before asking about sexual history with a female?

Menstrual history
30.28

What is the correct position for a womens pelvic exam?

Lithotomy

What is the correct way to look into the ear with an otoscope?

Pull the pinna up and backwards