Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?
A. 4+
4+: This indicates very brisk reflexes with possible clonus, which is more than just brisk reflexes.
B. 2+
2+: This indicates normal reflexes, not brisk.
C. 1+
1+: This indicates diminished or hypoactive reflexes, not brisk.
D. 3+
3+: This indicates brisk reflexes, which are faster than normal but without evidence of clonus.
This question is an excerpt from Nurse Dive's nursing test bank - Ati health assessment proctored exam. Take the full exam now
Full Explanation
A. 4+: This indicates very brisk reflexes with possible clonus, which is more than just brisk reflexes.
B. 2+: This indicates normal reflexes, not brisk.
C. 1+: This indicates diminished or hypoactive reflexes, not brisk.
D. 3+: This indicates brisk reflexes, which are faster than normal but without evidence of clonus.
Similar Questions
Which general survey question focuses on the common "fifth vital sign"?
A. "When was the last time you experienced a fever?"
"When was the last time you experienced a fever?": This question pertains to the assessment of body temperature, which is part of the vital signs but not the "fifth vital sign."
B. "Do you consider yourself a happy person?"
"Do you consider yourself a happy person?": This question focuses on emotional well-being, not the "fifth vital sign."
C. "Do you monitor your blood pressure regularly?"
"Do you monitor your blood pressure regularly?": This pertains to blood pressure monitoring, which is one of the vital signs but not the "fifth vital sign."
D. "Are you experiencing any pain right now?"
"Are you experiencing any pain right now?": Pain is often referred to as the "fifth vital sign" and is assessed to understand a patient's overall health and comfort.
Full Explanation
A. "When was the last time you experienced a fever?": This question pertains to the assessment of body temperature, which is part of the vital signs but not the "fifth vital sign."
B. "Do you consider yourself a happy person?": This question focuses on emotional well-being, not the "fifth vital sign."
C. "Do you monitor your blood pressure regularly?": This pertains to blood pressure monitoring, which is one of the vital signs but not the "fifth vital sign."
D. "Are you experiencing any pain right now?": Pain is often referred to as the "fifth vital sign" and is assessed to understand a patient's overall health and comfort.
The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?
A. Vesicular
Vesicular: Vesicular breath sounds are normal and are heard over most of the lung fields. They are soft and low-pitched.
B. Tracheal
Tracheal: Tracheal breath sounds are harsh and high-pitched, typically heard over the trachea rather than over most of the lung fields.
C. Bronchial
Bronchial: Bronchial breath sounds are loud and high-pitched, usually heard over the trachea and larynx, not over most lung areas.
D. Bronchovesicular
Bronchovesicular: These sounds are heard between the sternum and the interscapular area but are not as commonly heard over most of the lung fields compared to vesicular sounds.
Full Explanation
A. Vesicular: Vesicular breath sounds are normal and are heard over most of the lung fields. They are soft and low-pitched.
B. Tracheal: Tracheal breath sounds are harsh and high-pitched, typically heard over the trachea rather than over most of the lung fields.
C. Bronchial: Bronchial breath sounds are loud and high-pitched, usually heard over the trachea and larynx, not over most lung areas.
D. Bronchovesicular: These sounds are heard between the sternum and the interscapular area but are not as commonly heard over most of the lung fields compared to vesicular sounds.
The nurse who has been assigned to a client on the second shift is assessing a client to evaluate the outcomes identified in the care plan. This nurse is conducting which type of assessment?
A. Problem-oriented assessment
Problem-oriented assessment: This focuses on specific issues or symptoms rather than evaluating outcomes of an established care plan.
B. Follow-up history
Follow-up history: This type of assessment is conducted to evaluate the effectiveness of interventions and monitor progress towards outcomes identified in the care plan.
C. Comprehensive assessment
Comprehensive assessment: This involves a thorough evaluation of the client’s overall health status and history, not specifically focused on evaluating outcomes.
D. Emergency history
Emergency history: This is conducted in urgent situations to quickly assess and address immediate issues, not for evaluating outcomes of a care plan.
Full Explanation
A. Problem-oriented assessment: This focuses on specific issues or symptoms rather than evaluating outcomes of an established care plan.
B. Follow-up history: This type of assessment is conducted to evaluate the effectiveness of interventions and monitor progress towards outcomes identified in the care plan.
C. Comprehensive assessment: This involves a thorough evaluation of the client’s overall health status and history, not specifically focused on evaluating outcomes.
D. Emergency history: This is conducted in urgent situations to quickly assess and address immediate issues, not for evaluating outcomes of a care plan.