Test 2 practice questions NUR 1020c Questions With
Complete Solutions
5 RIGHTS of delegation Correct Answer Right person- do they
understand how to properly
Right situation- can it be done, are they stable ?
Right task- is this in their job scope
Right communication- tell them clearly
Right Supervision- are you confident with their skill level
5 steps of the nursing process Correct Answer Assessment
Diagnosis
Planning
Implementation
Evaluation
Actual diagnosis Correct Answer 3 parts (PES)
Problem (nanda approved)
Etiology (the cause)
Symptoms/signs ( as evident by )
affective learning Correct Answer Addresses the emotional
side of learning.
-example: a client listens to the nurse explain life changes
necessary to manage diabetes and then discusses feelings
regarding the diagnosis
after collecting and reviewing all assessment data, what will you
then do ? Correct Answer You will cluster the data
-you look for patterns and related data to support a nursing
diagnosis.
,Aniscoria Correct Answer pupils of unequal size
APIE Correct Answer Assessment
Problem
Intervention
Evaluation
areas where lymph nodes are accessible Correct Answer Head
and neck, arms, axilla and inguinal area
Auscultation Correct Answer technique of listening with a
stethoscope to sounds made by organ systems such as the heart
and GI system
Body systems model Correct Answer The body systems model
organizes data based on each system of the body.
Integumentary, respiratory, cardiovascular etc..
ex; My legs are painful when walking for a short time. Since the
complaint is confined to just the leg you would use the body
systems model.
Braden Scale Correct Answer used to determine the risk for
impaired skin integrity
cerebellar function tests Correct Answer
Equilibrium/movements
Test balance/gait/Romberg Test
, -watch person walk 10-20 feet, turn, and returns to starting
position- gait is smooth, effortless- 15 inches from heal to heal
- ask the pt to stand with eyes closed for 20 seconds (Romberg
sign)
cerebellar lower extremity test Correct Answer Heel to shin
test
- ask the pt to lay down, and run the heel of their foot down the
shin of the other leg.
CN 11 Spinal Accessory (XI) Correct Answer -Shrug both
shoulders against hands, turn face against hands.
-This nerve innervates the sternomastoid and trapezius
CN 12 Hypoglossal (XII) Correct Answer motor, tongue
movement
"stick out your tongue test'
CN 2 test Correct Answer confrontation test
CN 2: Optic Nerve (II) Correct Answer sensory, vision
CN 3: Oculomotor Nerve (III) Correct Answer this nerve is
responsible for movement of eyeball, raising of eyelid, and
change in pupil size
CN 4: Trochlear Nerve (IV) Correct Answer eye movement
CN 6: Abducens Nerve (VI) Correct Answer 6 cardinal fields
of gaze
Complete Solutions
5 RIGHTS of delegation Correct Answer Right person- do they
understand how to properly
Right situation- can it be done, are they stable ?
Right task- is this in their job scope
Right communication- tell them clearly
Right Supervision- are you confident with their skill level
5 steps of the nursing process Correct Answer Assessment
Diagnosis
Planning
Implementation
Evaluation
Actual diagnosis Correct Answer 3 parts (PES)
Problem (nanda approved)
Etiology (the cause)
Symptoms/signs ( as evident by )
affective learning Correct Answer Addresses the emotional
side of learning.
-example: a client listens to the nurse explain life changes
necessary to manage diabetes and then discusses feelings
regarding the diagnosis
after collecting and reviewing all assessment data, what will you
then do ? Correct Answer You will cluster the data
-you look for patterns and related data to support a nursing
diagnosis.
,Aniscoria Correct Answer pupils of unequal size
APIE Correct Answer Assessment
Problem
Intervention
Evaluation
areas where lymph nodes are accessible Correct Answer Head
and neck, arms, axilla and inguinal area
Auscultation Correct Answer technique of listening with a
stethoscope to sounds made by organ systems such as the heart
and GI system
Body systems model Correct Answer The body systems model
organizes data based on each system of the body.
Integumentary, respiratory, cardiovascular etc..
ex; My legs are painful when walking for a short time. Since the
complaint is confined to just the leg you would use the body
systems model.
Braden Scale Correct Answer used to determine the risk for
impaired skin integrity
cerebellar function tests Correct Answer
Equilibrium/movements
Test balance/gait/Romberg Test
, -watch person walk 10-20 feet, turn, and returns to starting
position- gait is smooth, effortless- 15 inches from heal to heal
- ask the pt to stand with eyes closed for 20 seconds (Romberg
sign)
cerebellar lower extremity test Correct Answer Heel to shin
test
- ask the pt to lay down, and run the heel of their foot down the
shin of the other leg.
CN 11 Spinal Accessory (XI) Correct Answer -Shrug both
shoulders against hands, turn face against hands.
-This nerve innervates the sternomastoid and trapezius
CN 12 Hypoglossal (XII) Correct Answer motor, tongue
movement
"stick out your tongue test'
CN 2 test Correct Answer confrontation test
CN 2: Optic Nerve (II) Correct Answer sensory, vision
CN 3: Oculomotor Nerve (III) Correct Answer this nerve is
responsible for movement of eyeball, raising of eyelid, and
change in pupil size
CN 4: Trochlear Nerve (IV) Correct Answer eye movement
CN 6: Abducens Nerve (VI) Correct Answer 6 cardinal fields
of gaze
