nurse 251 exam 1 Questions With Complete Solutions
3 non-therapeutic techniques to avoid
during an interview Correct Answer 1. false reassurance
2. probing
3. defensiveness
3-5 therapeutic techniques for communicating during an
interview Correct Answer 1. attentive/active listening
2. silence
3. focusing
4. using open-ended questions
5. clarification
A 30-year-old personal trainer has a resting heart rate of 48. The
nurse is not concerned, as this is an expected finding.
A. True
B. False Correct Answer True
Although bradycardia can be concerning in most cases, in well-
trained athletes, the heart muscle can develop along with the
skeletal muscles, thus a slower heart rate is normal.
A male patient is admitted to the Emergency Room after falling
and breaking his wrist. He is sweating, has a heart rate of 120,
and reports a pain level of 8 out of 10. What kind of pain is this
patient experiencing?
A. Visceral pain
B. Deep somatic pain
C. Cutaneous pain
D. Referred pain Correct Answer B (deep somatic pain)
,A source of deep somatic pain is from the bones, and the patient
has sustained a broken bone from a fall. Additionally, the patient
is exhibiting signs and symptoms of sweating and nausea
A nurse is assessing a patient in the
Neuroscience ICU who fell from a rooftop
and suffered a catastrophic brain injury. He
observes the patient's arms are stiff, the
arms are flexed inward and adducted, and
there is plantar flexion in the feet. How will
the nurse document this finding?
a. Decerebrate rigidity
b. Glasgow Coma Score of 6
c. Decorticate rigidity
d. Positive Babinski's sign Correct Answer C
The correct answer is Decorticate posturing; flexion and
adduction of the upper arms (curling inward toward the center of
the body along with extension, internal rotation, and/or plantar
flexion of the feet indicate decorticate posturing. Decerebrate
posturing indicates a more severe injury, and is marked by
extension and rotation outward (not inward) of the extremities.
The GCS was not tested in this question, although this patient
likely has a very low score, and
Babinski's sign, while abnormal in an adult, was also not tested
here.
**Remember deCORticate is curled into the CORE of the body,
while decerebrate curls away from the body. Both will be
described in similar ways, so pay attention to key words
,including placement of the arms and the direction they are
flexed.**
A nurse is assessing an adult client's vital signs with no
significant PMH. Vital signs are as follows: HR 114 bpm, RR
23 breaths per minute, BP 120/78 mmHg, temp of 37 C, and
pulse ox of 88%. Which vital signs are abnormal? Select all that
apply.
A. HR 114 bpm
B. RR 23 breaths per minute
C. BP 120/78 mmHg
D. Temp 37 C
E. Pulse ox 88% Correct Answer A, B, E (HR 114 bpm, RR
23 breaths per
minute, pulse ox 88%)
Average heart rate is between 60-100 bpm. The average
respiratory rate is between 12-20 breaths per minute, and a
healthy person with no lung disease should have a pulse ox of
95% or
greater. Remember your abbreviations that Brandi explains in
class; you'll not only see them countless times, but you'll be
using them in your notes and clinical assignments. (PMH = Past
Medical History.)
A nurse is preparing to count the respirations of an adult patient.
What should the nurse do?
A. Ask the patient to lie down in order to best observe their
breathing
B. Inform the patient that you are preparing to count his/her
respirations and to breathe
, naturally
C. Count the respirations for 15 seconds and then multiply by 4
to obtain the rate
D. Maintain position of counting radial pulse and unobtrusively
count respirations Correct Answer D (Maintain position of
counting radial
pulse and unobtrusively count respirations)
Since most people are unaware of their breathing, the nurse
should not mention that he/she will be counting respirations, as
this may alter the patient's normal breathing pattern. The nurse
should count respirations for a full minute and avoid the 15-
second interval, as the result can vary by a factor of + or - 4,
which is significant with a small number.
A nurse must assess cerebellar function using the Romberg sign.
How can the nurse promote patient safety during this exam?
a. Ask the patient to remain seated until she has finished her
exam.
b. Have another nurse in the room to observe during the exam.
c. Ask the patient to keep his eyes open throughout the test.
d. Stand within arm's length of the patient to provide support if
needed. Correct Answer D
Romberg's Sign can assess innate balance and posture. To
correctly perform the test, have the patient stand upright (not sit)
with feet together and their arms at their sides. Have them close
their eyes and remain still for 20 seconds. Some very minor
swaying may be seen, but if the patient has balance or
coordination issues they could potentially fall. Thus, ensuring
the nurse is within arms length to provide extra support is the
3 non-therapeutic techniques to avoid
during an interview Correct Answer 1. false reassurance
2. probing
3. defensiveness
3-5 therapeutic techniques for communicating during an
interview Correct Answer 1. attentive/active listening
2. silence
3. focusing
4. using open-ended questions
5. clarification
A 30-year-old personal trainer has a resting heart rate of 48. The
nurse is not concerned, as this is an expected finding.
A. True
B. False Correct Answer True
Although bradycardia can be concerning in most cases, in well-
trained athletes, the heart muscle can develop along with the
skeletal muscles, thus a slower heart rate is normal.
A male patient is admitted to the Emergency Room after falling
and breaking his wrist. He is sweating, has a heart rate of 120,
and reports a pain level of 8 out of 10. What kind of pain is this
patient experiencing?
A. Visceral pain
B. Deep somatic pain
C. Cutaneous pain
D. Referred pain Correct Answer B (deep somatic pain)
,A source of deep somatic pain is from the bones, and the patient
has sustained a broken bone from a fall. Additionally, the patient
is exhibiting signs and symptoms of sweating and nausea
A nurse is assessing a patient in the
Neuroscience ICU who fell from a rooftop
and suffered a catastrophic brain injury. He
observes the patient's arms are stiff, the
arms are flexed inward and adducted, and
there is plantar flexion in the feet. How will
the nurse document this finding?
a. Decerebrate rigidity
b. Glasgow Coma Score of 6
c. Decorticate rigidity
d. Positive Babinski's sign Correct Answer C
The correct answer is Decorticate posturing; flexion and
adduction of the upper arms (curling inward toward the center of
the body along with extension, internal rotation, and/or plantar
flexion of the feet indicate decorticate posturing. Decerebrate
posturing indicates a more severe injury, and is marked by
extension and rotation outward (not inward) of the extremities.
The GCS was not tested in this question, although this patient
likely has a very low score, and
Babinski's sign, while abnormal in an adult, was also not tested
here.
**Remember deCORticate is curled into the CORE of the body,
while decerebrate curls away from the body. Both will be
described in similar ways, so pay attention to key words
,including placement of the arms and the direction they are
flexed.**
A nurse is assessing an adult client's vital signs with no
significant PMH. Vital signs are as follows: HR 114 bpm, RR
23 breaths per minute, BP 120/78 mmHg, temp of 37 C, and
pulse ox of 88%. Which vital signs are abnormal? Select all that
apply.
A. HR 114 bpm
B. RR 23 breaths per minute
C. BP 120/78 mmHg
D. Temp 37 C
E. Pulse ox 88% Correct Answer A, B, E (HR 114 bpm, RR
23 breaths per
minute, pulse ox 88%)
Average heart rate is between 60-100 bpm. The average
respiratory rate is between 12-20 breaths per minute, and a
healthy person with no lung disease should have a pulse ox of
95% or
greater. Remember your abbreviations that Brandi explains in
class; you'll not only see them countless times, but you'll be
using them in your notes and clinical assignments. (PMH = Past
Medical History.)
A nurse is preparing to count the respirations of an adult patient.
What should the nurse do?
A. Ask the patient to lie down in order to best observe their
breathing
B. Inform the patient that you are preparing to count his/her
respirations and to breathe
, naturally
C. Count the respirations for 15 seconds and then multiply by 4
to obtain the rate
D. Maintain position of counting radial pulse and unobtrusively
count respirations Correct Answer D (Maintain position of
counting radial
pulse and unobtrusively count respirations)
Since most people are unaware of their breathing, the nurse
should not mention that he/she will be counting respirations, as
this may alter the patient's normal breathing pattern. The nurse
should count respirations for a full minute and avoid the 15-
second interval, as the result can vary by a factor of + or - 4,
which is significant with a small number.
A nurse must assess cerebellar function using the Romberg sign.
How can the nurse promote patient safety during this exam?
a. Ask the patient to remain seated until she has finished her
exam.
b. Have another nurse in the room to observe during the exam.
c. Ask the patient to keep his eyes open throughout the test.
d. Stand within arm's length of the patient to provide support if
needed. Correct Answer D
Romberg's Sign can assess innate balance and posture. To
correctly perform the test, have the patient stand upright (not sit)
with feet together and their arms at their sides. Have them close
their eyes and remain still for 20 seconds. Some very minor
swaying may be seen, but if the patient has balance or
coordination issues they could potentially fall. Thus, ensuring
the nurse is within arms length to provide extra support is the
