ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 27 Questions
Question 1 of 5
A nurse on a medical-surgical unit is caring for a group of patients. For which patient will the nurse perform a focused assessment?
Correct Answer: B
Rationale: After application of a cast, the nurse performs a focused neurovascular assessment, to assess circulation, sensation, and motor ability. A newly admitted patient requires a comprehensive assessment. The nurse performs an emergency assessment on a patient who presents with signs of acute respiratory difficulty. A postoperative patient without complications will receive ongoing assessments at regular intervals to evaluate the effectiveness of care and to assess for new problems.
Question 2 of 5
A nurse admitting a patient to a long-term care facility performs a functional assessment. Which questions will the nurse include as part of the assessment? Select all that apply.
Correct Answer: A,D,E
Rationale: A functional health assessment including strengths and areas needing improvement focuses on the effects of health or illness on a patient's quality of life. Questions about the patient's ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances are included. A history of smoking is a lifestyle factor, and the chief complaint is the reason for seeking health care; both are assessed during the health history. Social networks and support psychosocial factors are also assessed during the health history.
Question 3 of 5
A nurse in the neurology clinic is assessing a patient's eyes for extraocular movements. Which correctly describes the procedure for this test?
Correct Answer: B
Rationale: The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 ft away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal positions of gaze-up and down, left and right, diagonally up and down to the left, diagonally up and down to the right. Option B most accurately describes this procedure.
Question 4 of 5
A nursing student is learning to perform physical assessments. When will the student use the technique of palpation? Select all that apply.
Correct Answer: A,C,D
Rationale: During palpation, the nurse uses the sense of touch to compare bilateral pulses for symmetrical temperature, assess skin turgor, and check for enlarged lymph nodes. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds provide information about the location, shape, size, and density of tissues, such as dullness over a mass or fluid accumulation. Auscultation refers to listening with a stethoscope to sounds produced in the body; counting the apical pulse or auscultating heart sounds/murmurs are examples.
Question 5 of 5
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?
Correct Answer: A
Rationale: Jaundice refers to a yellowish skin color caused by liver, gallbladder, or pancreatic diseases. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.