Which of these is included in an assessment of general appearance?
a. Height
b. Weight
c. Skin color
d. Vital signs
ANS: C
General appearance includes items such as level of consciousness, skin color, nutritional status, posture, mobility, facial expression, mood and affect, speech, hearing, and personal hygiene. Height, weight, and vital signs are considered measurements.
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The nurse is instructing a nursing student when a new client comes to the eye clinic. The client explains that he thinks he has a corneal abrasion. The nurse should explain what to the student nurse?
A) "To detect corneal abrasions, an ophthalmoscope is used." B) "To detect corneal abrasions, ultrasonography is used." C) "To detect corneal abrasions, a slit lamp is used." D) "To detect corneal abrasions, retinal angiography is used."
A nursing home patient has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents?
A) Contact B) Droplet C) Airborne D) Positive pressure isolation
Parents planning on a vaginal birth after a cesarean birth (VBAC) should prepare:
1. Exclusively for a vaginal delivery. 2. Two birth plans: one for vaginal and one for cesarean. 3. For a long labor. 4. For a short labor.
To perform the Rinne test of hearing function, the nurse:
A) Whispers several words to the patient and asks him or her to repeat what was heard. B) Places a vibrating tuning fork in the middle of the head. C) Places a set of earphones over both ears, plays several tones, and asks the patient to identify the sounds heard. D) Uses a tuning fork to compare the length of time the patient hears sound conducted by the mastoid bone versus air conduction.