CPNRE Client Health Assessment 2 — Questions and Answers
Question 1: During a focused respiratory assessment, the practical nurse auscultates high-pitched musical sounds on exhalation. How are these best described?
- Crackles
- Wheezes (Correct answer)
- Stridor
- Rhonchi
Correct answer: Wheezes
Wheezes are high-pitched musical sounds from narrowed airways, heard primarily on exhalation, associated with asthma and COPD.
Wheezes: continuous, high-pitched musical sounds from air passing through narrowed airways (bronchospasm, mucus, foreign body); predominantly on exhalation; associated with asthma, COPD, anaphylaxis. Crackles (rales): discontinuous popping sounds from fluid in alveoli. Stridor: high-pitched inspiratory sound from upper airway obstruction. Rhonchi: low-pitched rumbling from secretions in larger airways. Accurate respiratory auscultation is a fundamental clinical assessment skill in Canadian practical nursing.
Question 2: A client opens eyes to voice, speaks confused words, and localizes pain. What is the Glasgow Coma Scale total?
- 9
- 10
- 11
- 12 (Correct answer)
Correct answer: 12
Eye opening to voice = 3, confused speech = 4, localizes pain = 5. Total GCS = 3+4+5 = 12.
GCS: Eye: 4=spontaneous, 3=to voice, 2=to pain, 1=none. Verbal: 5=oriented, 4=confused, 3=inappropriate, 2=sounds, 1=none. Motor: 6=obeys, 5=localizes, 4=withdraws, 3=abnormal flexion, 2=extension, 1=none. Calculation: 3+4+5=12. Normal GCS=15; GCS <=8 indicates severe brain injury. GCS is a standardized neurological assessment tool used across Canadian emergency and critical care settings.
Question 3: When assessing a wound for infection, which finding is most concerning?
- Slight pink discoloration at wound edges on day 2
- Increased warmth, redness, purulent drainage, and fever (Correct answer)
- Mild serosanguinous drainage in first 24-48 hours
- Approximated wound edges with mild bruising
Correct answer: Increased warmth, redness, purulent drainage, and fever
Warmth, redness, purulent drainage, and fever are classic signs of wound infection requiring prompt reporting and treatment.
Wound infection signs: warmth and erythema beyond wound edges; purulent (yellow, green, cloudy) drainage with foul odor; increasing pain; induration around wound; systemic signs (fever >38 degrees C, leukocytosis, tachycardia). Normal healing shows serosanguinous drainage (days 1-3) and approximated pink edges. The practical nurse must report infection signs promptly per Canadian IPAC wound management guidelines.
Question 4: The apical pulse is 96 bpm but the radial pulse is 78 bpm. How should this be documented?
- Tachycardia with regular rhythm
- Pulse deficit of 18 beats per minute (Correct answer)
- Bradycardia at 78 bpm
- Normal heart rate with peripheral vasoconstriction
Correct answer: Pulse deficit of 18 beats per minute
A pulse deficit is the difference between apical and radial rates (96-78=18), indicating some contractions lack sufficient force to produce a peripheral pulse.
A pulse deficit occurs when the apical rate exceeds the peripheral pulse rate (96-78=18). This indicates cardiac contractions too weak to generate sufficient stroke volume for a palpable peripheral pulse. Common causes: atrial fibrillation, PVCs, heart failure. The simultaneous apical-radial assessment identifies clinically significant dysrhythmias. Deficit >10 bpm warrants physician notification. This is part of the CPNRE cardiovascular assessment competency framework.
Question 5: In what order should abdominal assessment techniques be performed?
- Palpation, auscultation, percussion, inspection
- Inspection, auscultation, percussion, palpation (Correct answer)
- Inspection, percussion, palpation, auscultation
- Auscultation, inspection, percussion, palpation
Correct answer: Inspection, auscultation, percussion, palpation
Abdominal assessment sequence: inspection, auscultation, percussion, palpation. Auscultation precedes palpation to get unaltered bowel sounds.
For abdominal assessment: INSPECT (contour, symmetry, skin, visible peristalsis, umbilicus); AUSCULTATE (bowel sounds in all 4 quadrants - must precede palpation); PERCUSS (tympany over bowel, dullness over solid organs); PALPATE (light then deep). Palpation and percussion stimulate bowel activity and can alter bowel sound character, so auscultation comes first. This sequence is standard in Canadian nursing physical assessment education and CPNRE competency requirements.
Question 6: A postoperative extremity is pale, cold, and the client reports numbness and tingling. What does this indicate?
- Normal postoperative finding
- Compromised arterial circulation requiring emergency assessment (Correct answer)
- Venous congestion from dependent positioning
- Normal inflammatory response
Correct answer: Compromised arterial circulation requiring emergency assessment
Pallor, coolness, and paresthesias indicate compromised arterial circulation requiring emergency evaluation.
The 5 Ps of arterial compromise: Pain (out of proportion), Pallor (pale/mottled), Pulselessness, Paresthesia (numbness/tingling), Paralysis. Pale, cold extremity with paresthesias post-surgery suggests acute arterial compromise (vessel injury, thrombosis, compartment syndrome). Immediate physician notification is required since ischemia beyond 6 hours causes irreversible damage. 5P assessment is a core postoperative nursing competency in Canadian surgical nursing.
CPNRE Client Health Assessment 2
During a focused respiratory assessment, the practical nurse auscultates high-pitched musical sounds on exhalation.
How are these best described?