The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)

Tachypnea

Temperature

Turgor

Tympany

Answer and Explanation

Correct Answer : B,C

Normal skin temperature for healthy adults ranges between 92.3 and 98.4 Fahrenheit or 33-37 Celsius, far lower than the 98.6 F average core temp. Changes in skin temperature may indicate potential illness or injuries.

To check for skin turgor, the healthcare provider grasps the skin between two fingers so that it is tented up. Commonly the lower arm or abdomen is checked. The skin is held for a few seconds and then released. Skin with normal turgor snaps rapidly back to its normal position.

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Correct Answer is ["B","E"]

Explanation

A. Dilated pupils in response to dimmed lights are a normal response and not an indication of a

vision problem.

B. Pupils that remain dilated during an accommodation test indicate that the client may have an

issue with their autonomic nervous system and is not able to adjust their pupil size appropriately.

C. Far vision acuity of 20/20 bilaterally indicates normal vision.

D. A symmetrical pupillary light reﬂex response is a normal finding and not an indication of a vision

problem.

E. Frowning and squinting while reading the Snellen chart may indicate that the client is having difficulty seeing the letters clearly and may have a vision problem.

A. Punking B. Sexual violence C. Intimate partner violence D. Human violence

Correct Answer is D

Explanation

Human/interpersonal violence refers to violence that occurs between individuals, including physical, sexual, and psychological harm. It can occur in various forms and settings, including the examples you mentioned such as child maltreatment, sibling violence, bullying, elder abuse, hate crimes, and war/combat violence. These forms of violence can have serious and long-lasting consequences for the victims, their families, and society.

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The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client is experiencing a vision problem? (Select all that apply)

Correct Answer is ["B","E"]

Explanation

Child maltreatment, sibling violence, bullying, elder abuse, hate crimes and war/combat violence are types of?

Correct Answer is D

Explanation

The nurse would use which of the following skills first when examining the cardiovascular system of a patient?

The nurse is teaching the patient about diﬀerent stages of sleep. The nurse knows that REM sleep includes which one of the following?

The nurse should utilize what type of precaution when palpating the lips in a healthy adult?

The nurse assesses the patient's visual acuity to be 20/25 using an eye chart. The patient asks what that means. Which of the following is the nurse’s best response?

The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)

What term describes the amount of pain stimulation that is needed for an individual to feel pain?

When assessing the abdomen, the nurse would expect to auscultate which sounds?

When assessing the anus, the nurse should inspect for: (Select all that apply)