When assessing the central and peripheral arteries for bruits, what sound should normally be heard?
A) No sound
B) A swishing sound
C) S1 and S2
D) A murmur
A
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The nurse is assessing the fundus of the older adult client's eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which client symptom does the nurse anticipate?
1. Impaired central vision. 2. Impaired peripheral vision. 3. Consistently elevated serum glucose levels. 4. Uncontrolled hypertension.
The nurse suspects an older patient is having a grand mal seizure. What did the nurse observe in the patient?
1. Rhythmic jerking of the muscles 2. Rigid extremities lasting for several minutes 3. Brief loss of attention similar to daydreaming 4. Rigid extremities followed by rhythmic flexion
A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential for the nurse to set realistic goals for patient therapy and education?
1. The patient's functional status prior to illness 2. Family history of disease, diet history, and prior medical history 3. Demographic data including age, sex, race, and weight of patient 4. Cardiovascular risk factors, such as history of smoking and stress level
A registered nurse (RN) wants to delegate the insertion of an intravenous catheter (IV) to a licensed practical nurse (LPN/LVN). The RN bases the decision to delegate on which factor?
1. The RN does not have time to start the IV. 2. Inserting an IV catheter is within the scope of the LPN/LVN role according to the state's nurse practice act. 3. The RN has not started an IV since nursing school. 4. The RN does not have time to evaluate the outcome of the procedure.