ATI LPN
Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 21 : Physical Assessment Questions
Question 1 of 5
Describe the assessments that should be performed in relation to these limited data.
Correct Answer: D
Rationale: For a dehydrated, bedridden patient, assess skin turgor, mucous membranes, pressure ulcer risk, capillary refill, weight, urine output, edema, skin integrity, and mobility.
Question 2 of 5
Describe the assessments that you will perform to establish the status of his renal system and ensure that he is not getting into fluid overload problems.
Correct Answer: D
Rationale: Renal system assessment includes urine output, weight, edema, breath sounds, blood pressure, serum creatinine, BUN, fluid intake, and electrolyte levels to monitor for fluid overload.
Question 3 of 5
Score the patient responses on the Glasgow Coma Scale. Calculate the patient's total score. Would you consider this patient as having a significant neurological impairment?
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain (2), withdraws from pain (4), incomprehensible sounds (2), total = 8, indicating significant neurological impairment (score ?¤8 is severe).
Question 4 of 5
Abnormal sounds that can be auscultated over the lung fields are called
Correct Answer: A,B,C,D,E
Rationale: Abnormal lung sounds include crackles (rattling sounds), wheezes (high-pitched whistling), rhonchi (low-pitched rattling), stridor (high-pitched sound during breathing), and pleural friction rub (grating sound due to pleural inflammation).
Question 5 of 5
You have assessed the patient's pupils by shining a light into both pupils as you learned to assess both pupil reflexes and accommodation response. What acronym would you document that would indicate that all findings were within normal parameters?
Correct Answer: A
Rationale: PERRLA stands for Pupils Equal, Round, Reactive to Light, and Accommodation, indicating normal pupil findings.