3060 Final Exam CH 15-18, 24, 26, 27

An adult client has sought care at the clinic, stating that she believes she has ìa raging yeast infection.î The nurse would expect to assess what type of vaginal discharge? A) Thick, white vaginal discharge B) Copious clear, foul-smelling discharge C) Yellowish discharge with a metallic odor D) Blood-tinged vaginal discharge

A

When assessing the vaginal orifice of a young female client who has never been sexually active, the nurse notes a fold of fibrous tissue at the introitus. The nurse recognizes this as which structure? A) Labia B) Urethra C) Hymen D) Clitoris

C

When examining a newborn male infant, the nurse notes that neither testicle is descended. The nurse documents this finding as which of the following? A) Epididymitis B) Orchitis C) Cryptorchidism D) Varicocele

C

When palpating the Bartholin's glands, the nurse expresses a purulent discharge. Which of the following would be most appropriate for the nurse to do next? A) Recommend sitz baths. B) Palpate the uterus. C) Obtain a culture. D) Perform a rectal exam.

C

While inspecting the penis of a client, the nurse suspects herpes progenitalis based on which assessment finding? A) Red, oval ulcerations B) Hardened nodules on the glans C) Clear vesicles that erupt D) Painless, fleshy papules

C

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A) 2/5 B) 3/5 C) 4/5 D) 5/5

4/5

The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal? A) Absence of red glow on transillumination of sinuses B) Nasal mucosa pale pink and swollen C) Tonsils 2+ D) Pinkish, spongy soft palate

Pinkish, spongy soft palate

During a client's eye assessment, the nurse is testing for consensual pupillary constriction. Which technique should the nurse implement? -Hold a pencil about 12 inches from the tip of the nose -Use an ophthalmoscope to inspect the inner eye -Shine a light directly into one eye of the client -Place a barrier between the client's eyes

Place a barrier between the client's eyes

Assessment reveals that an older adult client has osteomalacia. Which of the following would be most important to include in the client's teaching plan? A) Practice risk prevention for fractures. B) Keep exercise to a minimum to decrease pain. C) Minimize movements to maintain joint stability. D) Treat secondary arthritis proactively.

Practice risk prevention for fractures.

A 66 y/o client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis? -Vertigo -Otalgia -Tinnitus -Presbycusis

Presbycusis

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? -Alcohol abuse -Recreational drug abuse -Smokeless tobacco use -Multiple sex partners

Smokeless tobacco use

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation? -Sternocleidomastoid muscle -Sternal notch -Submental space -Supraclavicular space

Sternal notch

A review of a client's history reveals cranial nerve IV paralysis. Which of the following would the nurse assess? -The eye cannot look to the outside side -Ptosis will be evident -The eye cannot look down when turned inward -The eye will look straight ahead

The eye cannot look down when turned inward

Scar tissue is visible on the perineum of an adult female client. The nurse should consequently question the client about which of the following? A) Surgical correction of a rectocele B) History of sexually transmitted infections C) History of sexual abuse D) Tearing during vaginal delivery

D

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A) Compact bone B) Red marrow C) Yellow marrow D) Spongy bone

Red marrow

A client who works in a plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing? -Limiting loud noise exposure to 1 hour a day -Taking a 10 minute break every 2 hours -Wearing ear protection when in the work environment -Cleaning ears regularly to prevent ear infections

Wearing ear protection when in the work environment

A client has sought care at the clinic, telling the nurse, "This ringing in my ears has gone on for weeks, and it's driving me crazy." The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions? A) Did your parents even complain of something similar?B) What medications are you currently taking? C) How would you describe your overall level of health? D) How do you usually clean your ears?

What medications are you currently taking?

The nurse is assessing the head and neck of a 51 y/o male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform? -Obtain a full set of vital signs -Percuss the client's thyroid -Auscultate the client's thyroid -Perform a swallowing assessment

Auscultate the client's thyroid

The nurse is assessing the genitalia of an older adult client. Which of the following would the nurse document as a normal finding? A) Decrease in size of the testes B) Testes hanging lower in the scrotum C) Abundant pubic hair D) Bulging in the inguinal area

B

The nurse is completing a client's genitourinary assessment and is preparing to assess the client's cervix. What finding would most clearly warrant referral? A) The cervix is firm on palpation. B) The cervix is immobile on palpation. C) The cervix is smooth and pink on inspection. D) The cervix projects 2 cm into the client's vagina.

B

The nurse is inspecting the cervix of a client who has two children. The nurse would expect the cervical os to appear as which of the following? A) Round B) Slit-like C) Transverse D) Stellate

B

The nurse is preparing a client for an assessment of her genitalia and rectum. What action should the nurse perform when preparing the client? A) Assist the client into a prone position. B) Explain the rationale for using foot stirrups. C) Reassure the client that no one other than the nurse will be in the room. D) Obtain written, informed consent for the examination.

B

A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instructions? -"I'm going to press on several different places below and in front of your ear." -"I'm going to put my fingers in front of your ears and ask you to open your mouth wide." -"Turn so I can see the side of your face and then open your mouth wide like you are yawning." -"When I place my hands on your cheeks, clench your teeth and then relax them."

"I'm going to put my fingers in front of your ears and ask you to open your mouth wide."

The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+

3+

A female client has presented for a Pap smear test, and the nurse is discussing risk factors for cervical cancer. What risk factor should the nurse describe? A) Having multiple sexual partners B) Previous treatment for chlamydial infection C) Pregnancy before age 21 D) African-American ethnicity

A

A male client is receiving chemotherapy for the treatment of cancer. Which finding should the nurse anticipate during examination of the client's genitalia? A) Sparse pubic hair B) Hardness along the ventral surface of the penis C) Cyanosis to the glans D) Tenderness on scrotal palpation

A

A postmenopausal woman tells the nurse that she experiences discomfort during sexual intercourse. Which of the following should the nurse suggest? A) Use of a lubricant B) Abstinence from intercourse C) Use of a condom by the partner D) Kegel exercises

A

When obtaining a cervical specimen for a Neisseria gonorrhoeae culture, which of the following would be most appropriate? A) Wipe the cotton-tipped applicator onto a slide. B) Spread the specimen in a "Z" pattern on a special culture plate. C) Immerse the swab in a liquid medium and refrigerate. D) Roll the endocervical brush onto a slide.

B

While assessing the scrotum of an adult client, the nurse notes thin and rugated scrotal skin with little hair dispersion. The nurse interprets this finding as which of the following? A) Reiter's syndrome B) Normal findings C) Effects of chemotherapy D) Gonorrhea

B

When assessing a client for possible oral cancer, the nurse should most closely inspect which area? A) Buccal mucosa B) Hard palate C) Area under the tongue D) Along the gum line

Area under the tongue

A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next? -Attempt to remove the splinter using sterile forceps -Irrigate the eye with dilute hydrogen peroxide -Arrange for worker to be promptly assessed by an eye specialist -Encourage the worker to see an optometrist as soon as possible

Arrange for worker to be promptly assessed by an eye specialist

The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, ìI'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies.î How can the nurse begin to identify the specific allergens that cause the man's symptoms? A) Ask the client if his allergies respond to OTC antihistamines. B) Ask the client about the timing of his allergy symptoms. C) Perform a detailed inspection of the client's ears and throat using an otoscope. D) Perform transillumination of the client's sinuses.

Ask the client about the timing of his allergy symptoms.

A nurse is assessing an adult client's eyes and vision. When performing the cover test, the nurse would cover one of the client's eyes and then do which of the following? -Ask the client to focus on a distant object, looking for movement in the other eye -Ask the client to close the other eye then open that eye quickly -Ask the client to follow the nurse's finger with the other eye -Ask the client to look directly at a light with the other eye

Ask the client to focus on a distant object, looking for movement in the other eye

A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform? -Assess the nasolacrimal sac -Inspect the palpebral conjunctiva -Test pupillary reaction to light -Perform the eye positions test

Assess the nasolacrimal sac

The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate? A) At the anterior area of the sternoclavicular joint B) At the posterior temporomandibular joint C) At the olecranon process of the elbow D) At the back of the wrist and extended thumb

At the back of the wrist and extended thumb

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion? A) Phalen's test B) Tinel's test C) Ballottement test D) Leg raising test

Ballottement test

A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebra? -C3 -C5 -C7 -T2

C7

The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse? A) Osteoarthritis B) Diabetic neuropathy C) Carpal tunnel syndrome D) Gouty arthritis

Carpal tunnel syndrome

A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, "Do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem? -Presbyopia -Cataracts -Nystagmus -Glaucoma

Cataracts

A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? A) Caucasian B) African American C) South Asian D) Native American

Caucasian

On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment? A) History of abuse B) Chronic nose picking C) Mucosal polyps D) Chronic allergies

Chronic allergies

A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition? A) Crepitus over the maxillary sinuses B) Frontal sinuses nontender to palpation C) Red, tender tympanic membrane D) Increased amounts of saliva production

Crepitus over the maxillary sinuses

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? -Penlight -Tongue depressor -Centimeter scale ruler -Cup of water

Cup of water

A client's health history reveals that she had a total hysterectomy at age 33 to treat severe endometriosis. She says that the surgeon also removed both ovaries and fallopian tubes. The nurse would interpret this as which of the following? A) Natural menopause B) Delayed menopause C) Premature menopause D) Artificial menopause

D

During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged and easily transilluminates. Which of the following should the nurse suspect? A) Tumor B) Hernia C) Varicocele D) Hydrocele

D

A male client has presented for follow-up to a diagnosis of genital warts. The nurse should expect to assess for what type of lesions? A) Reddened ulcers that occasionally bleed B) Pimple-like vesicles C) Firm, shiny nodules D) Moist, fleshy papules

D

A nurse is a preparing to assess a male client's anus and rectum. How should the nurse best prepare the client for this assessment? A) Ask the client if he is feeling anxious or fearful about the exam. B) Assist the client into the supine position. C) Administer a dose of analgesia 15 minutes before the exam. D) Position the client in a left side-lying position.

D

A nurse is performing transillumination as part of the assessment of a client's swollen scrotum. What finding constitutes a normal scrotum? A) The testes transilluminate, but the other regions of the scrotum do not. B) Transillumination of the scrotum results in a pale yellow or white glow. C) Transillumination of the scrotum results in a red glow. D) Contents of the scrotum do not transilluminate.

D

A nurse is preparing to examine a client's inguinal area. The nurse understands that this area is contained by which structure laterally? A) Symphysis pubis B) Inguinal ligament C) Inguinal canal D) Anterior superior iliac spine

D

During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density? A) Beta-adrenergic blockers B) Corticosteroids C) Nonsteroidal anti-inflammatories (NSAIDs) D) Calcium channel blockers

Corticosteroids

A nurse asks a client to bring his hands together behind his head with his elbows flexed. The nurse is testing which of the following? A) Abduction B) Adduction C) Internal rotation D) External rotation

External rotation

The nurse is conducting a focused musculoskeletal assessment of an older adult client. When analyzing assessment data, the nurse should be aware of what age-related physiological changes? SELECT ALL THAT APPLY A) Absence of knee flexion B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength

Decreased bone density Decreased joint flexibility Joint capsule calcification Reduced muscle strength

A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer? A) Would you say that you're prone to getting mouth ulcers? B) Do you brush and floss daily? C) Do you use tobacco, whether smoking or chewing? D) How often do you usually go to the dentist in a year?

Do you use tobacco, whether smoking or chewing?

A nurse is performing an eye assessment of an 81 y/o male client. Which of the following would the nurse document as a normal finding? -Ectropion -Episcleritis -Chalazion -Exophthalmos

Ectropion

Which of the following would the nurse expect to find when examining a client with a herniated lumbar disc? A) Rounded thoracic convexity B) Lumbar lordosis C) Flattened lumbar curve D) Lateral curvature of the spine

Flattened lumbar curve

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include? A) Circumduction B) Flexion C) Abduction D) Internal rotation

Flexion

A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem? -Episcleritis -Strabismus -Macular degeneration -Glaucoma

Glaucoma

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect? A) Gouty arthritis B) Rheumatoid arthritis C) Degenerative joint disease D) Plantar fasciitis

Gouty arthritis

Inspection of a client's foot reveals an enlarged, painful, inflamed bursa (bunion) on the medial side of the foot. The nurse should make a referral for what health problem? A) Osteomalacia B) Hallux valgus C) Pes planus D) Gouty arthritis

Hallux valgus

The nurse is assessing an older adult client whose health problems include receding gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask? A) Have you lost any teeth recently? B) How would you describe your typical diet? C) Has your dentist screened you for oral cancer recently? D) Are you able to taste the food you eat?

Have you lost any teeth recently?

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following should the nurse cite as a risk factor? A) Obesity B) Multiparity (multiple pregnancies) C) History of smoking D) African-American ethnicity

History of smoking

The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? A) How often do you use over-the-counter nasal sprays? B) How often do you take Tylenol? C) How many drinks of alcohol do you have in a typical day? D) Would you say that you eat a balanced diet?

How often do you use over-the-counter nasal sprays?

While performing an elderly client's admission assessment, the nurse notes the presence of deep tongue fissures. Which of the following responses should take priority? A) Anterior-posterior and lateral chest x-ray B) Complete blood count with differential C) Dietitian referral D) Intravenous fluid replacement

Intravenous fluid replacement

The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up? A) Thrush B) Leukoplakia C) Gingivitis D) Canker sore

Leukoplakia

A client has suffered a suspected a rotator cuff tear. Which of the following would the nurse expect to find? A) Limitation of all shoulder motion B) Chronic pain C) Limited abduction D) Sharp catches of pain with movement

Limited abduction

Which of the following would be most appropriate when the nurse notes limitation in active range of motion of a client's right shoulder? A) Test muscle strength. B) Perform passive range of motion test. C) Measure range of motion with a goniometer. D) Ask the client which is the dominant side.

Measure range of motion with a goniometer.

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? -Recent eye trauma -Narcotic use -Macular degeneration -Recent peripheral nervous system injury

Narcotic use

The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group? A) Italian Americans B) Native Americans C) African Americans D) Non-Hispanic Americans

Native Americans

Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes

Numbness

When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. The nurse would document this as which of the following? -Physiologic cup -Optic disc -Retinal vessels -Fovea

Optic disc

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data? -RC: Thyroid crisis -RC: Cerebrovascular accident -RC: Cushing's syndrome -RC: Acromegaly

RC: Cushing's syndrome

The results of a client's Rinne test are as follows: bone conduction and air conduction are both reduced. Which of the following would be most appropriate? -Perform a Romberg test -Take a swab of the client's tympanic member -Repeat the test in 5 to 10 minutes -Refer the client for further evaluation

Refer the client for further evaluation

When asked to touch her ear to her shoulder, a client reports pain. Which of the following should the nurse do next? A) Perform muscle strength against resistance. B) Refer the client for further evaluation. C) Flex and then hyperextend the neck. D) Palpate the paravertebral muscles for pain.

Refer the client for further evaluation.

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next? -Refer the client immediately for further evaluation -Assess the foreign body for inspection -Examine the postauricular cysts -Position the patient to facilitate drainage

Refer the client immediately for further evaluation

Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding? A) Swab the lesion to obtain a sample for culture and sensitivity testing. B) Recommend that the client gargle with saltwater twice daily for several days. C) Refer the client to her primary care provider promptly. D) Determine whether the lesion can be removed with a sterile cotton-tipped applicator.

Refer the client to her primary care provider promptly.

The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem? A) Risk for injury related to potential esophageal trauma B) Risk for oral infection related to dysphagia C) Risk for aspiration related to decreased swallowing ability D) Risk for excess fluid volume related to decreased peristalsis

Risk for aspiration related to decreased swallowing ability

Which test would be most appropriate for the nurse to perform when a client complains of low back pain? A) Straight leg test B) Muscle leg strength C) Lateral bending of cervical spine D) Internal rotation of the shoulders

Straight leg test

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding? -Diameter: 0.75 cm -Mobile -Tender -Discrete

Tender

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment? A) The client takes medications to treat hypertension. B) The client suffered a fractured humerus 1 year earlier. C) The client has a diagnosis of type 1 diabetes. D) The client had a total hip replacement 2 years ago.

The client had a total hip replacement 2 years ago.

The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following? A) The client's leg length B) The client's lateral bending ability C) The client's cervical ROM D) The client's gait

The client's gait

The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say "aaah." This finding should prompt the nurse to focus on which of the following during subsequent assessment? A) The client's nutritional status B) The client's neurological status C) The client's immune function D) The client's respiratory function

The client's neurological status

A client has presented for care because of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate which of the following? A) The physician will write a prescription for antibiotics. B) The drainage will need to be cultured. C) A repeat procedure will be done in 1 week to compare findings. D) The headaches are most likely not from a sinus infection.

The headaches are most likely not from a sinus infection.

A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance? A) Thick, white plaques on the tongue surface B) Dry appearance with fissures present C) Diffuse reddened lesions that bleed easily D) Firm, raised nodules that are pink or red

Thick, white plaques on the tongue surface

A teenage boy has been diagnosed with orchitis. When reviewing the child's health history, the nurse should expect that the client may have recently been treated for what health problem? A) Measles B) Varicella C) Phimosis D) Influenza A

A

An adult client has sought care because he has a two-day history of stool that is ìblack like road tar.î How should the nurse best respond to this aspect of the client's history? A) Promptly refer the client for treatment of a possible gastrointestinal bleed. B) Refer the client to a dietitian for treatment of a possible vitamin deficiency. C) Encourage the client to increase his intake of fluids and soluble fiber. D) Encourage the client to use an over-the-counter laxative for the next 2 to 3 days.

A

During the health history, a postmenopausal client mentions that she is experiencing vaginal dryness. When explaining the most likely reason to the client, the nurse should explain the role of which hormone? A) Estrogen B) Progesterone C) Follicle-stimulating hormone (FSH) D) Oxytocin

A

The nurse is assessing a client who is suspected of having an incarcerated scrotal hernia. Which finding would help confirm this suspicion? A) The mass cannot be pushed up into the abdomen. B) The area around the hernia is ecchymotic. C) The client complains of tenderness and nausea. D) A scrotal bulge disappears when the client lies down.

A

The nurse is inspecting the client's vaginal musculature and asks the client to bear down. Which finding would lead the nurse to suspect that the client has a cystocele? A) Bulging of the anterior vaginal wall B) Protrusion of the cervix C) Urine leakage D) Protrusion at the back of the vaginal wall

A

The nurse is presenting a program about sexually transmitted infections, including HIV, to a group of young men. The nurse would include which of the following as the having the highest incidence of HIV infection in the United States? A) Men having sex with men B) Heterosexual partners C) Bisexual individuals D) Intravenous drug users

A

While interviewing a teenage male client, the nurse reviews the various structures of the male genitalia. The client asks, ìSo what does this epididymis do?î Which of the following would the nurse include in the response? A) It allows sperm to mature. B) It transports sperm away from the testes. C) It separates the testes from the scrotal wall. D) It produces sperm and male sex hormones.

A

A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis? A) A 71-year-old man who has type 2 diabetes B) A 69-year-old woman with no major risk factors for osteoporosis C) A 37-year-old woman who takes oral contraceptives D) A 49-year-old African-American woman who is obese

A 69-year-old woman with no major risk factors for osteoporosis

An experienced nurse is aware that receding gums are an expected finding in some clients whereas in other clients this finding is abnormal. In which of the following clients would the nurse identify receding gums as an expected assessment finding? A) A 4-year-old girl who has all of her primary teeth B) A 20-year-old man who has type 1 diabetes mellitus C) A 39-year-old woman who has just finished a course of oral antibiotics D) A 77-year-old man who describes himself as being healthy

A 77-year-old man who describes himself as being healthy

A 55 y/o client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data? -Are you having any difficulty hearing high-frequency sounds? -Do you notice any drainage from your ears? -Are you experiencing any pain in your ears? -Have you felt any popping sensations in your ears?

Are you having any difficulty hearing high-frequency sounds?

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding? A) Repeated ear infections B) Trauma C) Age-related changes D) Acute otitis media

Acute otitis media

When testing muscle strength, a client has difficulty moving her right arm against resistance. Which of the following should the nurse do next? A) Move the part passively through its range of motion. B) Ask the client to move the part against gravity. C) Inspect by touch for a palpable contraction of the muscle. D) Percuss the client's shoulder joint

Ask the client to move the part against gravity.

A 49-year-old woman has sought care because of severe perimenopausal symptoms. The client has asked the nurse if she should talk to her doctor about beginning hormone replacement therapy (HRT). How should the nurse best respond? A) The most recent research suggests that the benefits of HRT have been greatly overstated. B) HRT often relieves many of the symptoms of menopause, but it's not without some risks. C) HRT is a good option for many women, mostly because it's a naturally occurring substance. D) Your doctor will likely recommend HRT because you're beginning menopause quite young.

B

A 52-year-old woman's current medication regimen includes estrogen-progestin therapy (EPT). In addition to reduced symptoms of menopause, the nurse should be aware that this therapy confers what secondary benefit? A) Weight loss B) Reduced risk of colorectal cancer C) Protection against stroke D) Increased libido

B

A client has a family history of prostate cancer and is committed to regular screening. What should the nurse teach the client about prostate-specific antigen (PSA) blood testing? A) Annual PSA blood testing should begin at age 50. B) PSA blood testing is not recommended for most clients. C) PSA blood testing should only be performed on men who reject digital rectal exams. D) PSA blood tests should be performed biannually between ages 45 and 60 and then annually thereafter.

B

A client has admitted to the nurse that he has been having difficulty obtaining and maintaining erections for many months. Which of the nurse's assessment questions most clearly addresses a potential cause for the client's problem? A) How would you describe a typical day's food intake? B) What medications are you currently taking? C) Have you ever been screened for prostate cancer? D) Do you ever experience pain when you urinate?

B

A client has sought care because of a sudden increase in the size of his scrotum. The nurse's assessment reveals the presence of a large scrotal mass. How can the nurse best assess for a scrotal hernia? A) Palpate the mass for pain. B) Auscultate the mass for bowel sounds. C) Percuss the mass for dullness. D) See if the mass disappears when the client stands.

B

A client's electronic health record reveals that he had surgery as an infant to correct the fact that his urethra was located on the ventral side of his penis. The nurse should recognize that this client had which of the following? A) Epispadias B) Hypospadias C) Paraphimosis D) Phimosis

B

A nurse is aware of the need to protect against false allegations of inappropriate physical touch during a client's genitourinary assessment. How can the nurse best address this risk? A) Thoroughly explain the rationale for each aspect of the assessment. B) Ensure that a chaperone is present in the room during the exam. C) Perform the assessment as quickly and efficiently as possible. D) Ask for the client's permission prior to starting the assessment.

B

A nurse is planning to assess a male client for urethral discharge. Which technique would be best for the nurse to use? A) Have the client hold the penis while the examiner looks for discharge. B) Gently squeeze the glans between the thumb and index finger. C) Inspect the scrotal skin while holding the penis aside. D) Observe the glans of the penis for signs of abnormal discharge.

B

A nurse is preparing a female client for a genitourinary examination that has been scheduled for later in the week. What anticipatory guidance should the nurse provide to the client? A) Stop taking any antibiotics for 24 hours before your examination. B) Make sure not to douche for 48 hours before the examination. C) Don't bathe or shower on the morning of the appointment. D) Drink at least 48 ounces of fluid the morning before the appointment.

B

An older adult client states, ìSometimes when I sneeze, I notice that I wet my pants.î The nurse interprets this as which of the following? A) Reflex incontinence B) Stress incontinence C) Urge incontinence D) Total incontinence

B

During the health history, a young male client asks the nurse why his scrotum rises and relaxes. The nurse would incorporate knowledge of which of the following when responding to this client? A) When the temperature is warm, the scrotum rises. B) The cremasteric reflex controls the rise and relaxation of the scrotum. C) When the scrotum relaxes, it has many rugae. D) If the temperature is colder, the scrotum relaxes.

B

In which of the following clients would the nurse consider a bluish tint to the cervix an expected assessment finding? A) A client who is 17 years old and sexually active. B) A client who is 10 weeks' pregnant. C) A 71-year-old multiparous client D) A client who has a 24 pack-year smoking history.

B

Palpation of a male client's urethra produces a yellowish-white discharge. What is the nurse's best action? A) Obtain a urine sample for culture and sensitivity testing. B) Obtain a sample of the discharge for culture. C) Ask the client to void and then repeat palpation of the client's urethra. D) Palpate the client's scrotum and testes for the presence of fluid.

B

The nurse is preparing to perform a rectovaginal examination on a client. Which statement by the nurse would be most appropriate? A) I have to do this exam to make sure everything is okay, so just bear with me. B) You might feel uncomfortable, almost like you have to move your bowels. C) Just relax, it will only take a minute and then I'll be all finished. D) I want you to hold your breath as I insert my fingers into the openings.

B

The nurse notes a malodorous, yellow discharge upon inserting the speculum into the client's vagina. Which of the following should the nurse do next? A) Obtain a urine specimen. B) Obtain a wet mount slide. C) Procure a Papanicolaou (Pap) smear. D) Perform a bimanual exam.

B

When inspecting a client's inguinal area for bulging, which of the following would be most appropriate for the nurse to have the client do? A) Bend forward from the waist B) Bear down as if having a bowel movement C) Hold his breath after exhaling D) Lie supine and draw his knees to his chest

B

A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse held a penlight 1 foot from the client's eyes and appraised the client's eye alignment in which of the following ways? -By comparing the reflection of the light on the client's eye surface -By comparing the speed of pupillary constriction -By comparing how quickly the client blinks each eyelid -By comparing the relative color of the sclerae before and after light exposure

By comparing the reflection of the light on the client's eye surface

A client complains of scrotal pain, and the nurse elicits a positive Prehn sign, in which passive elevation of the testes relieves the scrotal pain. The nurse should refer the client for treatment of which of the following? A) Strangulated hernia B) Tortuous varicocele C) Epididymitis D) Scrotal mass

C

A nurse teaches a male client how to perform testicular self-examination when the client's history reveals that he does not do it. The nurse should instruct the client to perform the self-examination at which frequency? A) Weekly B) Bimonthly C) Monthly D) Quarterly

C

An adult male client reports hesitancy when urinating. The nurse would further assess this client for which of the following? A) Scrotal hernia B) Sexually transmitted infection C) Prostate enlargement D) Testicular tumor

C

Assessment findings reveal that a client has herpes progenitalis. Which of the following would be most important to include in the teaching related to after the initial lesions disappear? A) The disease will spontaneously regress. B) The client is at increased risk for cancer of the glans. C) Recurrence can happen with varying frequency. D) The next outbreak will include moist, fleshy papules.

C

During the health history, the nurse teaches a client about toxic shock syndrome and ways to reduce her risks. The nurse determines that the teaching was successful when the client states which of the following? A) I will get a Pap smear regularly. B) It is important to use latex condoms. C) I should change tampons at least every 4 to 6 hours. D) I should stop using oral contraceptives.

C

The nurse is assessing a female client's genitourinary system. Which of the following findings would lead the nurse to suspect a problem with the ovaries during palpation? A) Slight tenderness on palpation B) Walnut-sized ovaries C) Immobile ovaries D) Smooth ovarian surface

C

The nurse is beginning the physical exam of a male client's genitals. The nurse is sitting on a stool in front of the client. In which position would be best to place the client? A) Lying supine B) Kneeling C) Standing D) Sitting

C

The nurse is preparing to perform a speculum examination on a client. The nurse lubricates the speculum with which of the following? A) Petroleum jelly B) Water-soluble lubricant C) Client's vaginal secretions D) Antimicrobial ointment

C

To examine the Bartholin's glands of a female client, the nurse would palpate at which anatomic location? A) On both sides of the clitoris B) Just inside the urethral orifice C) Between the vaginal opening and labia minora D) Inside the vaginal orifice

C

When assessing the cervix of an older postmenopausal woman, which of the following would the nurse document as a normal finding? A) Bluish color B) Bright red C) Pale pink D) White patches

C

While inspecting the vagina, the nurse observes a thin, grayish-white vaginal discharge with a fishy odor. Which of the following would the nurse suspect? A) Moniliasis B) Trichomoniasis C) Bacterial vaginosis D) Atrophic vaginitis

C

During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess? A) Asking if the client experiences dry mouth often B) Inspecting for inflammation of the tonsils C) Checking for a deviated nasal septum D) Performing a focused respiratory assessment

Checking for a deviated nasal septum

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? -Direct reflex -Optic chiasm -Consensual response -Accomodaton

Consensual response

The nurse is assessing an adolescent client and notes 45-degree flexion of the cervical spine. What is the nurse's most appropriate action? A) Facilitate a referral for medical follow up. B) Palpate the spinous processes. C) Perform the LasËgue test. D) Continue the exam because this curve is normal.

Continue the exam because this curve is normal.

When the nurse is examining a male client's genitalia, the client experiences an erection. Which of the following would be most appropriate for the nurse to do? A) Remain silent but continue the examination. B) Stop the exam and leave the room for a few minutes. C) Ask the client whether continuing the exam will embarrass him. D) Reassure the client that this is not unusual.

D

A client has been to the clinic multiple times in the past year with vaginal infections, the most frequent of which was candidiasis. The nurse would assess the client for symptoms most likely related to which condition? A) Intestinal parasites B) Urinary tract infections C) Hypothyroidism D) Diabetes mellitus

D

A young female client refuses treatment for a sexually transmitted infection. The nurse explains that lack of treatment may put her at risk for which condition? A) Endometriosis B) Urinary tract infection C) Cervical cancer D) Pelvic inflammatory disease

D

The nurse is assessing the genitalia and rectum of a 71-year-old client. When assessing the client's vagina, the nurse should know that age-related changes increase the client's risk of what abnormal finding? A) Trichomonas vaginitis B) Bacterial vaginosis C) Candidal vaginitis D) Atrophic vaginitis

D

The nurse is presenting a class to a group of high school students about sexually transmitted infections. Which of the following should the nurse include as a major risk factor for cervical cancer? A) Gonorrhea B) Chlamydia C) Syphilis D) Human papilloma virus

D

A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess? A) Joint dislocation B) History of fracture C) History of dental abscess D) Difficulty chewing

Difficulty chewing

A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? A) Flexion of 80 degrees B) Lateral bending of 35 degrees C) Hyperextension of 15 degrees D) Rotation of 30 degrees

Hyperextension of 15 degrees

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect? A) Meningitis B) Cervical strain C) Compression fracture D) Cervical disc degeneration

Meningitis

The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis? A) Resonance on percussion B) Dull sounds C) Tympanic sounds D) Pain on percussion

Pain on percussion

A client has presented with "a terrible head cold," and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? SELECT ALL THAT APPLY A) Inspection B) Palpation C) Auscultation D) Percussion E) Transillumination

Palpation Percussion Transillumination

The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next? A) Facilitate blood testing for human immunodeficiency virus (HIV). B) Refer the client to a primary care provider for medication. C) Asses the client's laboratory values for zinc deficiency. D) Assess the client for signs of jaundice.

Refer the client to a primary care provider for medication.

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? SELECT ALL THAT APPLY A) Risk for injury related to osteoporosis B) Risk for infection related to osteoporosis C) Activity intolerance related to osteoporosis D) Impaired physical mobility related to osteoporosis E) Disturbed sensory perception related to osteoporosis

Risk for injury related to osteoporosis. Activity intolerance related to osteoporosis. Impaired physical mobility related to osteoporosis.

A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as components of saliva? SELECT ALL THAT APPLY A) Salts B) Proteins C) Fats D) Mucus E) Amylase

Salts Mucus Amylase

The nurse can best palpate the superficial cervical nodes, deep cervical chain, and the supraclavicular nodes by first locating which muscle? -Infraspinous -Sternomastoid -Trapezius -Platysma

Sternomastoid

A nurse health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend? A) Washing with a warm, moist washcloth B) Gently irrigating with normal saline C) Cleaning with cotton-tipped applicator D) Irrigating with mildly soapy water

Washing with a warm, moist washcloth

The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination? A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation B) Whether the size of the client's knee changes throughout the joint's range of motion C) Whether swelling in the knee joint is a normal age-related change or a pathological finding D) Whether the client's knee joint is capable of adduction and abduction

Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A) III B) VI C) VIII D) XII

XII

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? -"I'm going to ask you to slowly walk forward until the last line of the chart becomes clear." -"Please stand at a comfortable distance from the chart and I'll get you to read each of the letters." -"Hold this chart and start to read out the letters after covering one of your eyes." -"Cover one of your eyes and then read out the letters on the chart, starting from the top."

"Cover one of your eyes and then read out the letters on the chart, starting from the top."

A client describes her frequent headaches as being severe and lasting for fays. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines? -"Do they occur after you have been tense or anxious?" -'When you consume alcohol, do you get a headache?" -"Do you have any eye symptoms, such as tearing?" -"Do you have any visual changes before the headache?"

"Do you have any visual changes before the headache?

A nurse is completing a comprehensive health history of a 69 y/o woman who is a new client of the clinic. Which of the nurses interview questions most directly addresses the client's risk for developing cataracts? -"Do you exercise regularly?" -"Have you ever been tested for diabetes?" -"Do you ever take over-the-counter pain medications?" -"At what age did you first start wearing glasses?"

"Have you ever been tested for diabetes?"

A nurse is conducting an assessment of a client's eyes and vision and has completed the positions test. Following this test, the nurse will be able to document data that addresses what aspects of eye health? SELECT ALL THAT APPLY -Distant visual acuity -Near visual acuity -Accommodation -Eye muscle strength -Cranial nerve function

-Eye muscle strength -Cranial nerve function

A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? SELECT ALL THAT APPLY -Sternocleidomastoid muscle -Hyoid bone -Cricoid cartilage -Carotid artery -Esophagus -Thyroid cartilage

-Hyoid bone -Cricoid cartilage -Thyroid cartilage

After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? SELECT ALL THAT APPLY -Lacrimal apparatus -Conjunctiva -Lens -Iris -Sclera -Caruncle

-Lacrimal apparatus -Conjunctiva -Caruncle

A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts? -A 55 y/o female client -A 40 y/o with arteriosclerosis -A client who has severe environmental allergies -A male client who is obese

A 55 y/o female client

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers? -Teaching about genetic screening -A nutritional health program -Teaching about a monthly self examination -A smoking cessation program

A smoking cessation program

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis? -Audible referred breath sounds at the site of the thyroid -An audible S3 sound at the site of the thyroid -A sound of turbulent blood flow in the thyroid -Irregular S1 and S2 rhythms in the thyroid

A sound of turbulent blood flow in the thyroid

A nurse is assessing a client who is suspected to have optic atrophy. Which of the following assessment findings is most consistent with this diagnosis? -Obscured retinal vessels -No visible physiologic cup -Increased appearance of the disc vessels -A white appearance of the optic disc

A white appearance of the optic disc

The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve? -Abducens (VI) -Accessory (XI) -Hypoglossal (XII) -Trochlear (IV)

Accessory (XI)

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal? -Acromegaly -Brain tumor -Paget disease -Parkinson disease

Acromegaly

Which of the following would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies? -Generalized redness -Pinguecula -Areas of dryness -Nodular appearance

Areas of dryness

While using an otoscope to assess the ears of an 8 y/o boy, the nurse observes white spots on the boy's tympanic membrane. The nurse also observes that no redness is present. Which action would be most appropriate? -Assess the boy for previous trauma to his skull -Determine whether impacted cerumen is present -Ask the mother whether the child has had numerous ear infections -Assess the child for further symptoms of acute otitis media

Ask the mother whether the child has had numerous ear infections

While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding? A) Have the client provide a 24-hour diet recall. B) Review the client's medication regimen. C) Prepare the client for a thyroid screening. D) Assess the client's cranial nerve function.

Assess the client's cranial nerve function

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands? -At the angle of the client's mandible -At the base of the client's skull -On the area behind the client's ears -Behind the tip of the client's mandible

Behind the tip of the client's mandible

A nurse is observing the red reflex in a client during as eye assessment. During this component of the assessment, the client states, "I hope you can see it because I have cataracts." What finding should the nurse expect? -Black spokes pointing inward -White arc around the limbus -Thickened bulbar conjuntiva -A red spot on the retina

Black spokes pointing inward

After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative? -Client moves the feet apart during the exam -Client sways moderately during the exam -Client maintains the position during the exam -Client starts to lose balance during the exam

Client maintains the position during the exam

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contradicted? -Asking the client to flex his or her neck -Compressing the arteries bilaterally -Performing the examination while the client is seated -Asking the client to swallow water

Compressing the arteries bilaterally

A 12-year-old boy has been brought to the emergency department after being hit in the head with a pitch during a baseball game. The emergency department nurse's comprehensive assessment includes examination of the boy's ears with an otoscope. What assessment finding would suggest trauma to the middle ear or inner ear? A) White spots on the tympanic membrane B) Dark red or bluish tympanic membrane C) Yellowish, bulging tympanic membrane D) Clear tympanic membrane

Dark red or bluish tympanic membrane

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age related physiological changes? -Increased size of a single thyroid nodule -A nonpalpable carotid pulse -Decreased strength of temporal artery pulsation -Tenderness of lymph nodes on palpation

Decreased strength of temporal artery pulsation

When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding? A) Enlarged pharyngeal tonsils B) Enlarged palatine tonsils C) Enlarged adenoids D) Enlarged lingual tonsils

Enlarged palatine tonsils

A client's history suggests a need to asses eye muscle strength and cranial nerve function. Which assessment should the nurse consequently perform? -Corneal light reflex test -Eye positions test -Cover test -Visual fields test

Eye positions test

The nurse is assessing a client whose EHR notes a diagnosis of esotropia. When examining this client, the nurse should expect which finding? -Eye turning outward -Eye malalignment -Eye turning inward -Eye oscillating

Eye turning inward

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? -Safe use of firearms -Safe use of machinery -Falls prevention -Domestic violence prevention

Falls prevention

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? -Far, then near -Lateral, then near -Near, then far -Lateral, then far

Far, then near

Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems? A) Frequent use of acetaminophen (Tylenol) B) Frequent use of cotton-tipped applicators inside the ear C) Preference for showers rather than baths D) In adequate hygiene practices

Frequent use of cotton tipped applicatiors inside the ear

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits? -Hyperextend the client's neck -Turn the client's head to the right -Have the client swallow water -Have the client hold his or her breath

Have the client hold his or her breath

A clinic client's primary complaint is earache (otalgia). Consequently, the nurse's assessment is focusing on potential causes of the client's pain. What question should the nurse include in the health interview? A) What do you do for a living? B) Do you know if your vaccinations are up to date? C) Do you take over-the-counter medications or supplements? D) Have you been swimming lately?

Have you been swimming lately?

When talking to a client before starting the physical exam, the nurse notes that the client's head is consistently tilted to one side. Which of the following would the nurse examine first? -Hearing acuity -Thyroid gland -Mental status -Lymph nodes

Hearing acuity

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? A) History of allergies B) Incomplete immunization record C) History of epistaxis (nosebleeds) D) Prolonged tonsillar enlargement

History of allergies

In the course of the nurse's health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client? A) Decreased sense of taste B) Difficulty hearing C) Impaired sense of smell D) Occasional dizziness

Impaired sense of smell

A nurse is performing an otoscopic exam of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place? A) In the center of the membrane B) In the 5 o'clock position C) In the 7 o'clock position D) In the upper left quadrant

In the 5 o'clock position

The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate? -Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing -Impaired social interaction, related to decreased ability to maintain contact with friends -Impaired verbal communication, related to lack of understanding of hearing deficit -Readiness for enhanced communication related to auditory integrity and need for hearing therapy

Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing

A client's EHR states that he has been diagnosed with sensorineural hearing loss. Which conduction should the nurse most likely identify as a cause? -Perforated eardrum -Otosclerosis -Inner ear problem -Otitis media

Inner ear problem

The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears? -Keeping the dominant hand away from the client's head -Inserting the speculum down and forward into the ear canal -Using the smallest speculum on the otoscope head -Holding the otoscope in the nondominant hand

Inserting the speculum down and forward into the ear canal

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first? -Assess the tympanic membrane -Palpate the client's tragus -Inspect the client's external ear canal -Perform hearing assessments

Inspect the client's external ear canal

A nurse is presenting a class to a local community group about vision and eye health. As part of the presentation, the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation? -It refers to a client's subjective appraisal of his or her vision -It begins with light rays striking the retina -It primarily involves the lens of the eye -It allows the eyes to focus on near objects

It begins with light rays striking the retina

A client asks why cerumen is important, stating, "It just clogs up the ears anyway."How should the nurse best describe the purpose of cerumen? -It helps protect the delicate eardrum from loud noise that may be damaging -It helps to keep the ear drum soft and functioning well -It helps to amplify the sound waves through the inner ear -It helps create the translucent, pearly color of the ear drum

It helps to keep the ear drum soft and functioning well

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles? -The thyroid gland is not normally palpable in female clients -Many clients have an additional (third) thyroid lobe -The thyroid gland is not normally palpable until clients are in their thirties and forties -Palpation creates a risk of rupturing the thyroid gland in some older adult clients

Many clients have an additional (third) thyroid lobe

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which of the following would the nurse most likely assess? -Sunken face -Drooping of one side -Masklike expression -Asymmetry of earlobes

Masklike expressioon

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? -Nodularity -Tenderness -Enlargement -Bruits

Nodularity

During a health history, a 62 y/o male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following? -Increased ocular pressure -Vitamin A deficiency -Normal findings for the client's age -Vascular spasm

Normal findings for the client's age

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? A) Scarring from previous infections B) Otitis media C) Normal tympanic membrane D) Otitis externa

Normal tympanic membrane

A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test? -Strabismus -Phoria -Tropia -Nystagmus

Nystagmus

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which of the following actions? -Observing the eye's reaction when a light is shone into the opposite eye -Shining a light into one eye while covering the other eye with an opaque card -Moving a finger into the client's peripheral vision field and asking the client to state when he or she sees a finger -Comparing the difference between the client's dilated pupil and a constricted pupil

Observing the eye's reaction when a light is shone into the opposite eye

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location? -On each side of the client's face, anterior and inferior to the ears -On each side between the top of the ear and the eye -Bilaterally, parallel to and anterior to the sternomastoid muscle -Inferior to the lower jaw beneath the client's tongue

On each side between the top of the ear and the eye

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first? A) Center of the client's forehead B) On the client's mastoid process C) In front of the client's external auditory canal D) At the base of the client's skull

On the client's mastoid process

A nurse palpates a client's ear and finds that the tragus is very tender. The nurse should suspect which of the following health problems? -Otitis media -Otitis externa -Ruptured tympanic membrane -Mastoiditis

Otitis externa

The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. Which of the following is the most likely etiology of this abnormal assessment finding? A) Otitis media B) Cranial nerve VIII damage C) Trauma to the temporal lobe D) Age-related hearing changes

Otitis media

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? -Pain radiating from eye to temporal region -Throbbing and severe pain -Report of ringing in the ears prior to headache -Complaint of sensitivity to light

Pain radiating from eye to temporal region

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? -Inspection -Auscultation -Palpation -Percussion

Percussion

A nurse is conducting a focused ear and hearing assessment of an adult client who has a history of mild hearing loss. When performing the whisper test, what instruction should the nurse begin with? A) Please close your eyes and listen carefully to what I say. B) Please cover your ear that has the weakest hearing. C) Please tell me when you can hear me talking. D) Please repeat the words that I say.

Please cover your ear that has the weakest hearing

The nurse is using an ophthalmoscope to examine a client's inner eye structures. What action should the nurse perform in order to accurately examine the client's optic disc? -Slowly approach the client's eye from a 90 degree angle, maintaining a focus on the pupil -Position the scope close to the client's eye and look through the pupil at a 15 degree angle -From a distance of 3 to 5 cm, examine the pupil from a 45 to 50 degree angle -While looking through the ophthalmoscope, approach the client's eye slowly from the side

Position the scope close to the client's eye and look through the pupil at a 15 degree angle

A nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. What health promotion and prevention activity should the nurse encourage these clients to perform? -Obtain a home version of the Snellen chart and test their vision weekly -Rinse their eyes with warmed, normal saline solution 3 to 4 times a week -Maintain a low sodium diet -Post an Amsler grid in their home and perform the test on a regular basis

Post an Amsler grid in their home and perform the test on a regular basis

A nurse is assessing the eyes of a 3 y/o child. Which finding would the nurse document as normal? -Pseudostrabismus -Tropia -Nystagmus -Exotropia

Pseudostrabismus

A 2-year-old girl has been brought to the ambulatory clinic by her mother who states, "She's put a pea in her ear, and I think she did it 2 days ago because that was the last time we ate them." The nurse's otoscopic examination confirms the presence of this foreign body in the girl's middle ear. How should the nurse best respond to this assessment finding? A) Attempt to remove the pea using sterile forceps. B) Irrigate the ear canal with warm tap water to remove the pea. C) Instruct the mother to watch the girl's ear closely and return for care if it does not fall out in the next few days. D) Refer the girl to her primary care provider for prompt removal of the pea.

Refer the girl to her primary care provider for prompt removal of the pea.

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize this as the need for what referral? -Referral for further assessment of thyroid function -Referral for assessment of cranial nerve function -Referral for assessment of lymphatic system function -Referral for further assessment of swallowing ability

Referral for further assessment of thyroid function

When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority? A) Determining whether the client is receiving phenytoin therapy B) Referring the client for further evaluation C) Encouraging the client to enroll in a smoking cessation program D) Providing the client with information on proper mouth care

Referring the client for further evaluation

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment? -Darwin tubercle -Red, flaky cerumen -Tender tragus -Pearly gray tympanic membrane

Tender tragus

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test? A) The client has unilateral hearing loss. B) The client has suspected otitis externa. C) The client is older than age 65. D) The client has a history of stroke.

The client has unilateral hearing loss

The nurse's assessment of an 81-year-old client's hearing has corroborated her recent history of hearing loss. The nurse questions the client about her use of hearing aids, to which the client responds, "I've got enough frustration in my life without having to fiddle with those." The nurse should suspect which of the following? A) The client may misunderstand the factors underlying her hearing loss. B) The client may have had a negative experience with hearing aids in the past. C) The client may be unable to afford the cost of hearing aids. D) The client may be unwilling to adhere to treatment regimens.

The client may have had a negative experience with hearing aids in the past.

A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe? A) Young children have a tendency to stick objects into their ear canal. B) The size and shape of children's eustachian tubes makes them vulnerable. C) Children's immune systems lack the maturity to fight infections. D) Children generally have poorer hygiene than adults.

The size and shape of children's eustachian tubes make them more vulnerable

During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following? -The good ear cannot receive sound vibrations. -There is a dysfunction of the middle ear. -The poor ear is receiving sound vibrations by air. -There is a sensorineural hearing impairment.

There is a sensorineural hearing impairment.

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include? A) Sit with the head of the bed at 45 degrees during meals. B) Be aware of the possibility of temporomandibular joint pain. C) Thoroughly chew small amounts of food with each mouthful. D) Drink fluids before and after, but not during, meals.

Thoroughly chew small amounts of food with each mouthful.

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem? -Trigeminal neuralgia -Migraine headache -Meningitis -Tempromandibular joint dysfunction

Trigeminal neuralgia

The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health? -Mental status -Hearing -Neurologic status -Vision

Vision