EAQ C Assessment FUND Quiz

Which technique would the nurse use when assessing a preschool-aged child? SATA. A. Asking questions directly to the child. B. Asking the child to sit on the examination table C. Having the child undress, leaving on the undergarments E. Asking the child whether the chest or stomach area is done first

-Asking questions directly to the child. -Asking the child to sit on the examination table. -Having the child undress, leaving on the undergarments -Asking the child whether the chest or stomach area is done first.

Within how many hours after a surgical procedure requiring general anesthesia would the nurse expect a client to void?

8 hours

What is a client inflamed pleura sound like and location?

Anterior lateral lung- Sound is Frictional rub

Which assessment technique would the nurse use to test a client's trigeminal nerve function?

Corneal sensation

Which factor is the nurse assessing when checking the cardinal postions?

Extraocular muscle functions

Which cranial nerves assist with both sensory and motor function? SATA

Facial Trigeminal

What does the Cranial nerve VII function?

Facial nerve and is concerned with facial expression, taste and the salivary glands.

Which parts of the body would be assessed for temperature in clients who abuse sedatives or hypnotics?

Forehead and Thorax

Which client has in unstageable injury?

Full-thickness loss in the tissue with the base of the injury covered by slough.

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue?

Hypoglossal

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student is incorrect?

If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given.

A registered nurse is teaching a nursing student about skin assessment. Which statement made by the nursing student is incorrect?

In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light.

Which questions would the nurse ask when assessing the mental health of a preschool-aged client? SATA.

Is your child experiencing nightmares? Does your child ask questions about the genitalia? How do you implement punishment when a rule is broken?

Define Cranial nerve VIII

Know as the vestibulocochlear nerve, assists with sensory functions such as auditory acuity.

Define Cranial V

Known as the trigeminal nerve, has both sensory and motor functions.

Define Cranial nerve X

Known as the vagus nerve, has both sensory and motor functions.

Which is a second degree burn?

Moist blebs, blisters, severe pain

Which client does the nurse suspect as having an iron deficiency?

Nail shape: Koilonychia- Flattening of the nail plate with an increased smoothness of the nail surface.

Which finding would the nurse expect when assessing a client who has a vertebral fracture at the T1 level?

Normal biceps reflexes in the arms

The registered nurse asks a client to rate their pain on a scale from 0 to 10, the instructs the nursing student to perform a physical assessment. Which steps by the nursing student would be included in a physical assessment for pain? SATA

Palpating for tenderness. Inspecting any areas of discomfort

When a client with chronic obstructive pulmonary disease is going to have a 6 minute test, which equipment will the nurse need to gather?

Pulse oximeter

What does the glossopharyngeal nerve (Cranial nerve IX) assist with?

Sensory perception such as taste at the posterior one third of the tongue.

During a period of heavy play, a first grader with a known history of anemia complains of feeling "woozy." Which action would be the school's nurse's initial response?

Sitting the child on a chair until the dizziness subsides

What is Otorrhea?

ear drainage

Which integumentary finding is related to skin texture?

Surface character

Which assessment would the nurse exclude when dealing with a client who has receptive and expressive aphasia?

Test the mental status by asking for feedback from the client

The nurse in the emergency department is assessing a client who has been physically and sexually assaulted. What is the nurse's PRIORITY during assessment?

The client's ability to cope with the situation

What is rhinorrhea?

runny nose

While assessing a client who sustained a road traffic accident, the nurse notices that the client is unable to clench teeth. Which cranial nerve might have been affected?

Trigeminal nerve

What does the Cranial nerve X function?

Vagus nerve and is concerned with the gag reflex, supplying parasympathetic fibers to body organs, & transmitting sensory impulses form the viscera.

Which findings would be MOST important to communicate to the health care provider after the nurse assesses a client's head and neck for respiratory problems?

Polyps on the nasal mucosa

The client report difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. Which is the purpose of the nurse's actions?

Data collection

After a head injury, a client reports ringing noises. Which area would the nurse assess further?

Eighth cranial nerve (Vestibulocochlear)

The nurse uses a tongue blade placed to the side of the child's tongue to examine the child's throat to avoid which problem?

Eliciting the gag reflex

What does the cranial nerve II function?

Optic nerve and is concerned with sight.

Which findings would the nurse expect to identify when assessing a client with a herniated lumbar disk?

Pain radiating to the hip and leg

What does the facial nerve (Cranial nerve XII) assist with?

Sensory functions such as a taste perception of the anterior two thirds of the tongue.

What is battle's signs?

A Battle's sign may be an indication of a serious head injury. Battle's sign is a crescent-shaped bruise that appears behind one or both ears.

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis from the medical record is consistent with this findings?

Bell palsy

During an assessment, the nurse shines a light into the clients eyes and observes that the pupil remains dilated. Which cranial nerve (CN) would the nurse suspect to be affected?

CN III (Oculomotor nerve)

Which component is important in a neurovascular assessment performed by the nurse?SATA

Capillary refill, Pulse and skin temperature, Movement and Sensation

Damage to which cranial nerve may lead to decreased olfactory acuity?

Cranial nerve I

Which age-related finding would the nurse identify while assessing the reproductive health of an older adult female?

Decreased amount of pubic hair

A adolescent reports scrotal plan, redness, dysuria, and fever. Which condition is the client MOST likely experiencing?

Epididymitis

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. Which score on the Lovett scale would be given to this client?

Good (G)

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. Which condition would the nurse observe upon the assessment?

Inhibition of tear production

When a previously healthy 24 year old client tells the nurse, "I sometimes feel my heart racing or skipping beats," Which question would the nurse ask?

How much caffeine do you consume each day

During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess?

I (Cranial nerve I)

Which positioning would be avoided while assessing a client with a history of asthma?

Lateral recumbent. That is used to assess heart function

Which cranial nerve would the nurse assess further for a client whose mouth is drooping over to the left?

Left facial nerve (Seventh cranial nerve). Has motor and sensory functions.

Which landmark is correct for the nurse to use when auscultating the mitral valve?

Left fifth intercostal space, midclavicular line

A client has a brain attack (Stroke) that involves the right cerebral cortex(outermost layer. Plays a role in memory, thinking & emotions.) and cranial nerves. Which area of paralysis would the nurse expect to find upon assessment? SATA.

Left leg, Left arm, & Left side of face.

The nurse is performing a skin assessment of a client. Which findings may indicates a risk of skin cancer? SATA.

Lesion, Lumps, Rashes

The nurse would recognize that which assessment finding is an early indication of heat inhalation?

Nasal discharge that contains carbon particles.

A registered nurse is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients?

Oral cavity

The nurse assesses the vital signs of a 50 year old female client and documents the results. Which finding is considered within normal range for this client?

Oral temperature of 98.2 F (36.8C). Apical pulse of 88 beats/min and regular. Blood Pressure of 116/78 mmHg while in a sitting position.

Which anatomic area is palpated if the nurse suspects aortic (aorta) abnormalities?

Palpation of the epigastric area. (Located at the tip of the sternum)

The nurse is assisting a primary health care provider to perform an examination of the reproductive tract of a female client. Which nursing actions are beneficial for the client? SATA

Providing nonjudgmental support to the client. Asking the client to empty the bladder before the examination. Assisting the client to a recumbent position on the examination table.

What does the trigeminal nerve (Cranial nerve V) assist with?

Sensory perception from the skin of the face and scalp and the mucous membranes of the mouth and nose. Also with the motor functions of the mouth such as mastication (chewing).

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. Which technique would be the nurse's next assessment?

To assess for swelling, warmth, and muscles firmness