310 test 4 prep u

A client is being discharged home from the hospital. This client has a history of falling at home. A caregiver is not able to stay with the client all the time. What can be done to decrease the risk for falling at the client's home? Select all that apply.

. Correct environmental hazards in the home • Install grab bars in the bathroom • Make sure house hallways are well lit

A patient in the clinic where you work is considered legally blind. You know that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less

The nurse is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following?

3+

How would you document normal muscle strength?

5/5

Which of the following assessment findings suggests a problem with the client's cranial nerves?

A client's extraocular movements are asymmetrical and she complains of diplopia.

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

Which of the following clients is most likely to be diagnosed with migraine headaches?

A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

The nurse assesses the frontal sinus where?

Above the eyes

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

Ask the client to remove the glasses before testing.

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side

A diabetes educator is teaching a group of adults about the risks to vision that result from poorly controlled blood glucose levels. Which of the following pathophysiologic processes underlies the vision loss associated with diabetes mellitus?

Blood vessels supplying the retina become weak and bleeding occurs.

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely

Candida albicans infection.

A 50-year-old realtor comes to the office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, the nurse notes pain and spasm over the paraspinous muscles on the left side of the neck, and pain when the client does active range of motion of the cervical spine. What is the most likely cause of this neck pain?

Cervical sprain

The nurse identifies this as trapping debris and propelling it toward the nasopharynx.

Cilia

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

Cup of water

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Diabetes

An elderly client presents to the healthcare clinic with reports of decreased tearing in both eyes. The nurse observes the presence of entropion. What is an appropriate action by the nurse?

Document the finding as a normal sign of aging

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing?

Effusion in the knee joint

The nurse is inspecting Wharton's ducts. The nurse would expect to find these at which location?

Either side of frenulum on floor of the mouth

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?

Female gender

The nurse is assessing the range of motion (ROM) of a patient's joints. What would the nurse use to assess flexion and extension of a joint if the patient complains of pain on examination?

Goniometer

Which of the following tools would a nurse practitioner be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a client?

Goniometer

What is the most common type of hyperthyroidism?

Graves' disease

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray

Assessment of the musculoskeletal system usually proceeds from general to specific and from?

Head to toe

What is vital in maintaining vision and a healthy outlook for clients?

Health education

Which finding should a nurse recognize as a normal when assessing the ears of an elderly client?

High tone frequency loss

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?

History of allergies

A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The mother states no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

Inspect the nostrils with an otoscope

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus

During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source such as infection in the area that it drains

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor?

Low estrogen levels

When examining the eye with an ophthalmoscope, where would you look to visualize the optic disc?

Medially toward the nose

What are the glands that are located on the tarsal plates and open on the lid margins?

Meibomian glands

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

Nonreaction of the opposite pupil to light

What is the common channel for the respiratory and digestive systems?

Oropharynx

The client is complaining that his lower joints are increasingly painful as the day progresses. The nurse suspects the client is experiencing what musculoskeletal disorder?

Osteoarthritis

A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following?

Otitis externa

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

A nurse examines the ear of a client diagnosed with an obstructed eustachian tube. What finding should the nurse anticipate upon assessment?

Prominent landmarks on the tympanic membrane

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following?

Pronation

On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?

Right homonymous hemianopsia

A 68-year-old retired banker comes to your clinic for evaluation of left shoulder pain. He swims for 30 minutes daily each morning. He notes a sharp, catching pain and a sensation of something grating when he tries overhead movements of his arm. On physical examination, you note tenderness just below the tip of the acromion in the area of the tendon insertions. The drop arm test is negative, and there is no limitation with shoulder shrug. The client is not holding his arm close to his side, and there is no tenderness to palpation in the bicipital groove when the arm is at the client's side, flexed to 90 degrees, and then supinated against resistance. Based on this description, what is the most likely cause of his shoulder pain?

Rotator cuff tendinitis

You are the school nurse in the local high school. You note that a 15-year-old girl carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem?

Scoliosis

A nurse should assist a client to assume what position in order to best assess the mouth, nose, and sinuses?

Sit with the head erect and at the eye level of the nurse

A community health nurse is attending a seminar on headaches. What would this

Stiff neck

A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a heavier-than-usual set of boxes. He also states that he has numbness and tingling in the left leg. What test should the nurse perform to assess for a herniated disc?

Straight leg raise test

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

The open space between the eyelids is called what?

The palpebral fissure

An nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus

The nursing instructor is discussing the difference between sesorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss?

The sound is better in the ear in which he has better hearing.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones

A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?

Tongue fissures

When assessing a patient you note that the tonsils are touching the uvula. How would you document the tonsils?

Tonsils are T3

During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following?

Trigeminal neuralgia

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment

Which cranial nerve is associated with the movement of the uvula?

Vagus (CN X)

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:

Vestibule, nasal passages, and nasopharynx

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

XII

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for

acromegaly

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of

acute otitis media.

The middle layer of the eye is known as the

choroid layer.

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

cleanse the cornea and the lens.

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's

corneal reflexes.

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should

document the findings in the client's records.

Before examining the mouth of an adult client, the nurse should first

don clean gloves for the procedure.

The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents

entropion

Primary headaches are more worrisome than secondary headaches.

false

Joints may be classified as cartilaginous, synovial, or

fibrous.

What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor?

flexion

An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of

herniated intervertebral disc.

Articulation between the head of the femur and the acetabulum is in the

hip joint

On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n)

increased thoracic curve

Bones in synovial joints are joined together by

ligaments

A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7 °C (100 °F). The nurse suspects the client is experiencing symptoms of

migraine headache.

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

migraine headache.

A client with insulin-dependent diabetes visits the clinic and complains of painful hip joints. The nurse should assess the client carefully for signs and symptoms of

osteomyelitis

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test

requires the covering of each eye separately.

Photoreceptors of the eye are located in the eye's

retina

The nurse is going to test range of motion in a patient. To test extension of the triceps muscle, the nurse would instruct the patient to

straighten the elbow

An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been

taking antibiotics.

A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should

tell the client that these often occur with aging.

Skeletal muscles are attached to bones by

tendons

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

tension headaches.

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?

trush

The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply.

• photophobia • recurrent • throbbing