ST. PAUL UNIVERSITY QUEZON CITY Formal Assessment 5, Summer 2013 NCM02 Health Assessment (Mr.

. Jeffrey Layosa, RN, MSN )

Name________________________________________Date___________Score _________________

I. Concept recall. Choose the best answer among the choices. Write your answer before the number using capital letters. Strictly no erasures or alterations of answer.

_____1. To assess Babinski reflex, which of the following is the appropriate action? a. Gently tap the antecubital area, with reflex hammer. b. present an aromatic substance to the patient while his eyes are closed. c. stroke the lateral aspect of the sole of the foot from heel to the ball. d. ask the patient to stand , with feet together with eyes closed. _____2. To assess the function of the abducens, the nurse asks the patient to do which of the following? a. shrug the shoulders b. follow movement of the nurses finger c. shift the gaze from far to near effect d. frown, smile, show the teeth _____3. The normal resting size of the pupil is? a. 1-3mm b. 3-5mm c. 5-8mm d. 8-12mm _____4. Which of the following is a common change in the curvature of the spinal cord among elderly? a. lordosis b. scoliosis c. kyphosis d. lateral scoliosis _____5. A deep tendon reflex of a score of 0 is? a. normal impulses b. diminished impulses c.hyperactive impulses d. Absent impulses _____6. The nurse is testing the coordinated functioning cranial nerves III, IV, and VI. To do this correctly, the nurse would test the: a. Corneal reflex b. Pupil response to light

c.Six cardinal fields of gaze d.Pupil response to light and accommodation _____7. The nurse is planning to test the function of the trigeminal nerve. The nurse would gather which of the following items to perform the test? a. tunning fork and audiometer b. snellen chart c. flashlight, pupil size chart or millimeter ruler d. safety pin, hot and cold water in test tubes, cotton wisp. _____8. the nurse was ask to determine if the patient can able identify different colors, she will use a: a. snellen chart d. tunning fork c. ishihara book d.water colors _____9. This is a standardized, objective assessment that describes level of consciousness by giving it a numeric value: a. Cranial nerve assessment b. Glasgow coma scale c.Romberg test d. None of the above _____ 10. Nurse Maria Ozawa is about to send his patient to the diagnostic room for Magnetic Resonance Imaging (MRI). What are the things she should remind to her client before going to the diagnostic room? a. b. c. d. Please shampoo your hair thoroughly because electrodes will be attached on your head. Do you have allergies in eating sea foods? Ill check first if your nail polish are already removed. Do you still have any metal object in your body?

_____ 11. Nurse Mina is about to send his client for CT-Scan, before leaving, what are the things she should check if her patient is for CT-scan without contrast? a.Do you have any allergies in eating seafoods? b. Ill ask my patient to sign the consent form after the doctor discuss what will happen during the procedure. c. Ill shampoo her hair thoroughly so that electrodes will be attach firmly. d. none of the above. _____ 12.Ear drops are prescribed for an infant with otitis media. The most appropriate method to administer the ear drops to the infant is: a.pull up and back on the pinna and direct the solution onto the eardrum. b. pull down and back on the pinna and direct the solution onto the eardrum. c. pull down and back on the pinna and direct the solution toward the wall of the ear canal. d.pull up and back on the earlobe and direct the solution toward the wall of the ear canal.

_____13. The nurse is evaluating the status of a client who had craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of the surgery if the client exhibits: a. (-) kernigs sign. b. absence of nuchal rigidity. c. positive brudzinskis sign. d. GCS score of 15 _____14. The client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the ff. to ensure clients safety? a. speak loudly to the client. b. test the temperature of the shower water. c. Check the temperature of the food on the dietary tray. d. provide a clear path for ambulation without obstacles.
_____ 15. The Glasgow scale is a systematic neurologic assessment tool that evaluates all of the

Following areas, EXCEPT: a. Eye opening b. Motor response

c. papillary reaction d. verbal response

Test II. Essay 1. Patient Eduardo is scheduled for Lumbar Puncture, He ask his nurse what are the things he should do after the procedure. In conducting a health teaching about Lumbar puncture, what do you think is the content of this activity? (5 points)

2. Nurse Mina is about to assess a patients level of consciousness who were involved in a vehicular accident, As a competent nurse she knows that the content of Glasgow Coma Scale in 3 areas (Eye opening, Motor and Verbal response) are:

Christ-centered person who is simple, warm and active with passion for service. Paulinian Catholic education for social transformation.

1. While performing a cardiovascular assessment, you palpate a carotid thrill. What sound would you expect to hear when auscultating the carotids? a.. Bruit b. No sound c. Murmur d. Venous hum

6. Which of the following is the most common symptom of myocardial infarction? a. Chest pain b. Dyspnea c. Edema d. Palpitations 7. Which of the following landmarks is the corect one for obtaining an apical pulse? a. Left intercostal space, midaxillary line b. Left fifth intercostal space, midclavicular line c. Left second intercostal space, midclavicular line d. Left seventh intercostal space, midclavicular line 8. A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this? a. Aortic b. Mitral c. Pulmonic d. Tricuspid 9. Which of the following complications is indicated by a third heart sound (S3)? a. Ventricular dilation b. Systemic hypertension c. Aortic valve malfunction d. Increased atrial contractions 10. Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client? a. Bruit b. Crackles c. Dullness d. Friction rubs

Ob
1. The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of: a. Mongolian spots b. Scrotal rugae c. Head lag d. Vernix caseosa An infant's Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is: a. The baby is cold. b. The baby is experiencing bradycardia. c. The baby's hands and feet are blue. d. The baby is lethargic.

2.

3.

The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to: a. Determine lung maturity b. Measure the fetal activity c. Show the effect of contractions on fetal heart rate d. Measure the well-being of the fetus

Neuro test
4. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes: a. Pain on flexion of the hip and knee b. Nuchal rigidity on flexion of the neck c. Pain when the head is turned to the left side d. Dizziness when changing positions The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: a. Agnosia b. Apraxia c. Anomia d. Aphasia The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as: a. Chronic fatigue syndrome b. Normal aging c. Sundowning d. Delusions

5.

6.

Christ-centered person who is simple, warm and active with passion for service. Paulinian Catholic education for social transformation.