The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is C
Explanation
A. This would show a regular rhythm with a consistent rate (60-100 bpm) and clear P waves before each QRS complex, which is not present in asystole.
B. This indicates a slow heart rate (below 60 bpm) but would still display P waves and QRS complexes; asystole shows no electrical activity.
C. This is the correct interpretation as it represents a flatline on the ECG, indicating no electrical activity in the heart.
D. This would show a rapid heart rate (above 100 bpm) with present P waves, which is not the case in asystole.
Correct Answer is C
Explanation
A. Cranial nerves III, IV, and VIII are not involved in mouth functions; they primarily deal with eye movements and hearing.
B. Cranial nerves III, II, and VI are involved in vision and eye movement but not in mouth functions.
C. Cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal) are all tested through functions such as swallowing, speech, and movement of the tongue, which occur in the mouth.
D. Option D incorrectly lists cranial nerve I twice; cranial nerve I (olfactory) is related to the sense of smell, not the mouth.