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 patient has come to the emergency department with symptoms of a stroke. During the assessment, the nurse asks the patient to raise their eyebrows, smile, and show their teeth to evaluate which cranial nerve?
Correct Answer: C
Rationale: Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise their eyebrow, smile, and show their teeth. The olfactory nerve (cranial nerve I) is tested by testing the sense of smell using various familiar substances. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.
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
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.
Question 4 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 5 of 5
A nurse is performing a breast assessment using the circular technique for palpation, gently compressing the breast tissue against the chest wall. How does the nurse proceed with the examination?
Correct Answer: A
Rationale: During breast assessment, the nurse palpates each quadrant of the breasts in a systematic method using the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse begins at the tail of Spence and moves in increasingly smaller circles. In the wedge method, the nurse works in a clockwise direction and palpates from the periphery toward the areola. In the vertical strip method, the nurse begins at the outer edge of the breast, palpating up and down the breast.