A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on the ventilator for 3 weeks. You are completing your initial assessment and are evaluating her skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage to the subcutaneous tissue. The underlying muscle is not affected. You identify this as a pressure ulcer. What is the stage of this ulcer?

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help:

While auscultating heart sounds, the nurse hears a bruit Which of these should be used to assess this bruit?

While the nurse examines a patient’s pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?

Which of the following screening tests has an expected finding of AC (air conduction) >BC (conduction) sound?

During an examination, the nurse notices a patterned injury on a patient’s back. Which of these would cause such an injury?

The most important step that the nurse can take to prevent transmission of microorganisms in the hospital setting is to:

All of the following are true about the review of systems (ROS), EXCEPT?

During an assessment, the nurse asks a patient with low back pain what has been used to try to alleviate the pain. The nurse is asking questions to determine which category of the mnemonic OLD CART?