solution
Winnie: Which of the following would be the most appropriate for you as the student
nurse to do next?
A. Leave Mrs Bago to go and talk to the other residents about what happened.
B. Perform a Glasgow Coma Score (GCS).
C. Refer the patient for immediate follow-up.
D. Ask if the patient has ever had a seizure
B. Perform a Glasgow Coma Score (GCS).
Winnie Bago: When performing a physical examination of Winnie which of the following
would be most appropriate?
A. Allow Winnie to remain dressed.
B. Omit intrusive parts of the exam.
C. Dim the room light.
D. Try to minimise position changes for her.
D. Try to minimise position changes for her.
Winnie: Which test would be most appropriate to perform when assessing Winnies eye
muscle strength and cranial nerve function?
A. Visual fields test.
B. Cover test.
C. Corneal light reflex test.
D. Extra ocular movement test.
D. Extra ocular movement test.
Winnie: Which of the following nursing assessments will give you objective data relating
to the functioning of Winnies cerebellum?
A. Vital signs.
B. Coordination.
C. Glasgow Coma Score
D. Cardiac function.
B. Coordination.
Winnie: The registered nurse is having difficulty eliciting a patellar reflex. Which of the
following would be most appropriate for the nurse to have Winnie do?
A. Lock the fingers together and pull against each
B. other. Stretch the arms over head.
C. Squeeze a thigh with the opposite hand.
D. Clench the jaw tightly.
A. Lock the fingers together and pull against each
Winnies patellar reflex is normal. Which of the following is the correct number to
document this?
A. 2+
B. 3+
C. 4+
D. 5+
A. 2+
, Winnie: Which of the following would be the most likely sign of a frontal lobe contusion?
A. Inability to hear high-pitched sounds
B. Difficulty speaking
C. Blurred vision
D. Loss of tactile sensation
B. Difficulty speaking
Joyce Collins: For which patient condition would you most likely expect a capillary refill
time longer than two seconds?
A. Malignant melanoma.
B. Inflammatory bowel disease.
C. Peripheral vascular disease.
D. Multiple sclerosis.
C. Peripheral vascular disease.
Joyce Collins: Which one of the following is a myth about pain in the older adult?
A. Opioids are often the drug of choice for some types of pain, and are to be used
cautiously.
B. Older patients may have more than one source of pain.
C. There is a greater likelihood of having developed a pathological condition that may
be accompanied by pain.
D. Elderly people who are confused or cognitively impaired do not have pain.
D. Elderly people who are confused or cognitively impaired do not have pain.
Joyce: As part of your cardiovascular assessment you are going to assess Joyce's
apical impulse. What is the correct location to auscultate the apical impulse?
A. Fourth intercostal space, left midclavicular line.
B. Second intercostal space, right midclavicular line.
C. Third intercostal space, mid axilla.
D. Fifth intercostal space, left mid clavicular line.
D. Fifth intercostal space, left midclavicular line.
Joyce: Which of the following represents the break in sounds between the first and
second sounds when auscultating Joyce's blood pressure?
A. Diastolic value.
B. Korotkoff sounds.
C. Auscultatory gap.
D. Phase V.
C. Auscultatory gap.
Joyce: You are having difficulty auscultating Joyce's heart sounds, specifically S1 and
S2. Which of the following would help?
A. Use the bell of the stethoscope to help distinguish the sounds.
B. Palpate the apical impulse.
C. Palpate the carotid pulse while auscultating the heart.
D. Determine the pulse deficit.
C. Palpate the carotid pulse while auscultating the heart.
Joyce: Which type of pain would be associated with arthritis?
A. Somatic
B. Chronic