BNMN 501 Assessment - Questions With Expert
Solutions
The nurse uses the Braden scale in the extended care facility to determine a
patient's risk for pressure ulcer development. Based on this scale which one of
the following scores, places the older patient at the highest level of risk?
Right Ans - 12
Which test would be most appropriate for the nurse to perform when
assessing eye muscle strength and cranial nerve function? Right Ans - Extra
ocular movement test
An hallucination is a disorder of? Right Ans - Perception
A 55 year old patient is being evaluated for hearing impairment. Which
question would provide the most useful information Right Ans - "are you
having difficulty hearing high frequency sounds?"
A false fixed belief that is out of keeping with a person's knowledge and
culture is known as a? Right Ans - Delusion
Pressure injuries form primarily from? Right Ans - poor nutrition/ tissue
necrosis
A nurse is preparing to assess the distant visual acuity of a patient who wears
reading glasses. which of the following would be most appropriate? Right
Ans - Ask the patient to remove the glasses before testing
A nurse is having difficulty determining a patient's heart sounds, specifically
S1 and S2. Which of the following would be appropriate for the nurse to do?
Right Ans - Use the bell of the stethoscope to help distinguish the sounds
What is the name given to the condition where the patient has an acute
confusional state, stemming from an infection? Right Ans - Delirium
A patient complains of headaches each morning that disappear after getting
out of bed. Which of the following would be the most appropriate for the
, nurse to do next? Right Ans - Use an appropriate framework to find out
more information about the headaches
When a patient is immobile, how often should the patient have a position
change to prevent skin breakdown? Right Ans - *Two hourly
A nurse is preparing to assess an adult patient's body temperature. At which
time of the day would the nurse expect to obtain the lowest body
temperature? Right Ans - Early morning
A novice nurse is practicing how to complete a comprehensive assessment to
gain confidence and skill. Which of the following would be most important for
the nurse to remember? Right Ans - *Establish a routine for the assessment
Which one of the following is a myth about pain in the older adult? Right
Ans - Elderly people who are confused or cognitively impaired do not have
pain
When a patient is in a supine position, what are the potential sites of pressure
injury the nurse should assess? Right Ans - Unprotected pressure points at
sacrum, heels, scapulae, elbows and back of head
Prolonged, intense pressure affects cellular metabolism by decreasing or
obliterating blood flow, resulting in tissue ischemia and ultimately tissue
death. There are four stages of pressure injury formation. The nurse observes
partial-thickness skin loss involving the epidermis and possibly dermis. What
will the nurse document in the patient records? Right Ans - Stage II
Nurses should be aware of the verbal and non-verbal ways patients can
communicate discomfort. What would be an appropriate assessment tool to
use with young children? Right Ans - A faces pain scale
What is the name given to the progressive deteriorating organic mental
disorder that is associated with the ageing process? Right Ans - Dementia
The nurse is auscultating a patient's blood pressure, and identifies which of
the following as the portion of blood pressure cycle reflecting the break in
sounds occurring between the first and second sounds? Right Ans -
Auscultatory gap
Solutions
The nurse uses the Braden scale in the extended care facility to determine a
patient's risk for pressure ulcer development. Based on this scale which one of
the following scores, places the older patient at the highest level of risk?
Right Ans - 12
Which test would be most appropriate for the nurse to perform when
assessing eye muscle strength and cranial nerve function? Right Ans - Extra
ocular movement test
An hallucination is a disorder of? Right Ans - Perception
A 55 year old patient is being evaluated for hearing impairment. Which
question would provide the most useful information Right Ans - "are you
having difficulty hearing high frequency sounds?"
A false fixed belief that is out of keeping with a person's knowledge and
culture is known as a? Right Ans - Delusion
Pressure injuries form primarily from? Right Ans - poor nutrition/ tissue
necrosis
A nurse is preparing to assess the distant visual acuity of a patient who wears
reading glasses. which of the following would be most appropriate? Right
Ans - Ask the patient to remove the glasses before testing
A nurse is having difficulty determining a patient's heart sounds, specifically
S1 and S2. Which of the following would be appropriate for the nurse to do?
Right Ans - Use the bell of the stethoscope to help distinguish the sounds
What is the name given to the condition where the patient has an acute
confusional state, stemming from an infection? Right Ans - Delirium
A patient complains of headaches each morning that disappear after getting
out of bed. Which of the following would be the most appropriate for the
, nurse to do next? Right Ans - Use an appropriate framework to find out
more information about the headaches
When a patient is immobile, how often should the patient have a position
change to prevent skin breakdown? Right Ans - *Two hourly
A nurse is preparing to assess an adult patient's body temperature. At which
time of the day would the nurse expect to obtain the lowest body
temperature? Right Ans - Early morning
A novice nurse is practicing how to complete a comprehensive assessment to
gain confidence and skill. Which of the following would be most important for
the nurse to remember? Right Ans - *Establish a routine for the assessment
Which one of the following is a myth about pain in the older adult? Right
Ans - Elderly people who are confused or cognitively impaired do not have
pain
When a patient is in a supine position, what are the potential sites of pressure
injury the nurse should assess? Right Ans - Unprotected pressure points at
sacrum, heels, scapulae, elbows and back of head
Prolonged, intense pressure affects cellular metabolism by decreasing or
obliterating blood flow, resulting in tissue ischemia and ultimately tissue
death. There are four stages of pressure injury formation. The nurse observes
partial-thickness skin loss involving the epidermis and possibly dermis. What
will the nurse document in the patient records? Right Ans - Stage II
Nurses should be aware of the verbal and non-verbal ways patients can
communicate discomfort. What would be an appropriate assessment tool to
use with young children? Right Ans - A faces pain scale
What is the name given to the progressive deteriorating organic mental
disorder that is associated with the ageing process? Right Ans - Dementia
The nurse is auscultating a patient's blood pressure, and identifies which of
the following as the portion of blood pressure cycle reflecting the break in
sounds occurring between the first and second sounds? Right Ans -
Auscultatory gap
