RPN Client Assessment and Planning 2 — Questions and Answers
Question 1: A client's Glasgow Coma Scale score is 3. What does this indicate?
- Mild confusion
- Moderate impairment
- Deep coma or no response (Correct answer)
- Normal consciousness
Correct answer: Deep coma or no response
A GCS score of 3 is the lowest possible score, indicating deep coma or no response to stimuli.
Question 2: When performing a head-to-toe assessment, which system should the RPN assess first?
- Integumentary
- Neurological (Correct answer)
- Cardiovascular
- Respiratory
Correct answer: Neurological
Neurological status is assessed first in a head-to-toe approach, beginning with level of consciousness.
Question 3: A client reports pain rated 8/10. Which action is the PRIORITY in the assessment phase?
- Administer ordered analgesic immediately
- Document the pain rating in the chart
- Assess pain characteristics using PQRST (Correct answer)
- Notify the physician of severe pain
Correct answer: Assess pain characteristics using PQRST
A thorough PQRST pain assessment must be completed before any intervention to guide appropriate care.
Question 4: Which finding during abdominal assessment requires IMMEDIATE reporting?
- Bowel sounds every 10 seconds
- Soft, non-tender abdomen
- Rigid, board-like abdomen (Correct answer)
- Mild bloating after meals
Correct answer: Rigid, board-like abdomen
A rigid, board-like abdomen may indicate peritonitis or internal bleeding and requires immediate physician notification.
Question 5: An RPN is assessing a client's peripheral pulses. A pulse graded as 1+ indicates:
- Bounding pulse
- Normal pulse
- Weak, thready pulse (Correct answer)
- Absent pulse
Correct answer: Weak, thready pulse
A 1+ pulse is weak and thready, suggesting diminished cardiac output or peripheral vascular disease.
Question 6: Which assessment tool is MOST appropriate for screening an older adult for cognitive impairment?
- Glasgow Coma Scale
- Mini-Mental State Examination (MMSE) (Correct answer)
- Beck Depression Inventory
- Braden Scale
Correct answer: Mini-Mental State Examination (MMSE)
The MMSE is a validated tool for screening cognitive function in older adults, assessing orientation, memory, and language.
Question 7: A client has a respiratory rate of 28 breaths/min and SpO2 of 91%. The RPN should FIRST:
- Reposition the client and reassess
- Document findings and continue monitoring
- Administer supplemental oxygen and notify the charge nurse (Correct answer)
- Encourage deep breathing exercises
Correct answer: Administer supplemental oxygen and notify the charge nurse
Tachypnea with hypoxia (SpO2 <95%) is an urgent finding requiring oxygen therapy and escalation.
RPN Client Assessment and Planning 2
A client's Glasgow Coma Scale score is 3.
What does this indicate?