Exam 4 Study Guide

The nurse is assessing the functions of the thyroid gland in a patient. Which body parts would the nurse assess in this exam? Multiple selection question Eye Ear Skin Hair Nose

Eye Skin Hair

Which features of the neck would the nurse inspect as part of a thorough assessment? Fullness Symmetry Lymph nodes Alignment of trachea Masses, webbing, skinfolds

Fullness Symmetry Alignment of trachea Masses, webbing and skinfolds

Increased intraocular pressure causes: A. Glaucoma B. Cataracts C. Macular Degeneration D. Presbyopia

Glaucoma

Loss of central vision may cause A Mental issues B Great distress C Reduced ability to perform ADLS D Balance problems

Great distress

As part of the head and face assessment, which features would the nurse assess by palpation? Hair distribution Skull size and shape Temporomandibular joint space Size and shape of the thyroid gland Symmetry and smoothness of the skull

Hair distribution Temporomandibular joint space Size and shape of the thyroid gland Symmetry and smoothness of the skull

During the head and face assessments, which features would be assessed by inspection? Head position Facial features Tics and spasms Facial symmetry Facial skin thickness Skull size and shape

Head position Facial features Tics and spasms Facial symmetry Skull size and shape

Though rarely used, normally, rectal temperatures measure _______ in infants and young children than in adults. Lower Higher

Higher

Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head A. Subdural hemotoma B. Hydrocephalus C. Spinal meningitis D. Internal skull fracture

Hydrocephalus

Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing

Inner ear

During the physical examination, ___________ always comes first. A. Inspection B. Palpation C. Auscultation D. Percussion

Inspection

Which element of the assessment should be performed with the patient seated and wearing a gown? Percussion of the posterior chest Inspection of facial symmetry Auscultation of heart sounds Palpation of axillary lymph nodes

Inspection of facial symmetry

You can test near vision for your patients using a: Jager Card Hold up two fingers technique PERRLA exam Peek a boo technique

Jager Card

Diagnostic positions test involves: Retinal response Leading eyes through six cardinal positions of gaze Retinal accommodation Pupillary reaction

Leading eyes through six cardinal positions of gaze

Consistency changes from that of soft plastic at birth to rigid glass in old age A. Iris B. Lens C. Optic disc D. Macula

Lens

Most common cause of blindness is: A. Diabetes Mellitus B. Loss of central vision C. Glaucoma D. Corneal dryness

Loss of central vision

Area of sharpest and keenest vision is the: A. Optic disc B. Retina C. Macula D. Cornea

Macula

Breakdown of cells in macula of retina is called: A. Presbyopia B. Cataracts C. Diabetes-related blindness D. Macular Degeneration

Macular Degeneration

Palpation of the thyroid and cervical lymph nodes is included in examination of which part of the body? Eyes Neck Mouth Pharynx

Neck

Observing the patient's gait and testing balance are included in which element of the adult head-to-toe examination with patient standing? Spinal Abdominal Neurologic Musculoskeletal

Neurologic

Which element is performed after inspection and palpation of the patient's spine while the patient is standing? Test abdominal reflexes Palpate axillary lymph nodes Assess radial and brachial pulses Observe the patient walk heel to toe

Observe the patient walk heel to toe

______________ or Postural Vital Signs, Take serial measurements of pulse and blood pressure in the following situations: You suspect volume depletion Person is known to have hypertension or taking antihypertensive medications Person reports fainting or syncope Position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur

Orthostatic

Which element of the assessment should be performed after assessment of the patient's back, posterior chest, and lungs? Weber test Palpation of apical impulse Palpation of posterior chest Inspection of spine and scapula

Palpation of apical impulse

Which examination component should be performed while the adult patient is supine with the legs exposed? Palpation of breast tissue Palpation of popliteal pulse Palpation of inguinal hernia Palpation for aortic pulsation

Palpation of popliteal pulse

___________ ____________: note child's interactions with parents, that parent and child show a mutual response and are warm and affectionate, appropriate to child's condition A. Childlike bonding B. Parental bonding C. Closeness bonding D. Relationship bonding

Parental bonding

Pulse force recorded using _-_______ scale

3 point

The nurse is examining the cranial x-ray of a patient undergoing treatment for a fractured cranium. Which bones will the nurse see in the x-ray? Multiple selection question Parietal Zygomatic Occipital Temporal Frontal

Parietal Occipital Temporal Frontal

In resting adult, normal heart rate range is __ to ___ beats per minute (bpm)

60 to 100

Macula, area of keenest vision, is absent at birth but mature by _ months A. 6 B 10 C. 12 D. 8

8

Normal oral temperature in a resting person is 98.6° with a range of ____ to ____. Rectal measures ___ to ____ degrees higher

96.4° F to 99.1°, 0.7° F to 1° F

Healthy person with no lung disease and no anemia normally has an SpO2 of __% to __% A. 95 to 100% B. 99-100% C. 97-98% D. 93-98%

97% to 98%

The nurse is assessing a patient with a heart rate of 55. Which of the following patients would be most likely to have a pulse rate of 55? A 70-year-old telephone salesman who is dehydrated A 20-year-old runner who had surgery 4 days ago for a fractured leg A 67-year-old who presented with an exacerbation of his COPD An infant who has a temperature of 100.1°F

A 20-year-old runner who had surgery 4 days ago for a fractured leg

Use of a Snellen chart includes: An optometrist Position person exactly 20 feet from chart Total silence Positive reinforcement

Position person exactly 20 feet from chart

As people age, the lens loses elasticity, becoming hard and glasslike which decreases ability to change shape to accommodate for near vision; called: A. Astigmatism B. Presbyopia C. Cataracts D. Macular degeneration

Presbyopia

Size determined by balance between parasympathetic and sympathetic chains of autonomic nervous system. A. Pupils B. Brain hemispheres C. Biceps D. Feet

Pupils

PERRLA stands for: Pupils ________, _________, __________ to Light, and _____________

Pupils Equal, Round, React to Light, and Accommodation

If rhythm is ___________, count number of beats in 30 seconds and multiply by 2 A. Irregular B. Regular C. Steady D. Arrythmic

Regular

Which aspects of the scalp should the nurse inspect as part of a thorough infant head and neck assessment? Scaling Shape Movement Smoothness Temperature

Scaling Shape

Which element of the functional assessment should be included during the review of systems? Blood pressure Ability to bathe Neurologic function Signs of dementia

Signs of dementia

Pupil ____ also reacts to amount of ambient light and to accommodation, or focusing an object on retina A. Color B. Direction C. Sharpness D. Size

Size

The assessment of financial resources and health insurance is included in which element of the functional examination? Social situation Review of systems Physical examination Activities of daily living

Social situation

Unequal pupil size, anisocoria - What is the concern if this is a new finding?

Stroke

As part of a thorough head and neck assessment, the nurse should assess which features of the infant head by palpation? Skin color Suture lines Fontanels Neck muscle tone Skull depressions

Suture lines Fontanels Neck muscle tone Skull depressions

To assist in the examination of the soft palate of a young child, what question can the nurse ask the patient? "Do you brush your own teeth?" "Can you pant like a puppy?" "Can you take a deep breath?" "Did you have any surgeries on your mouth when you were a baby?"

"Can you pant like a puppy?"

A more rapid heart rate, over ___ bpm, is tachycardia

100

Average BP in young adult is ___/__ mm Hg; varies normally with many factors

120/80

Normal pulse rate is __

2+

In adult, a heart rate less than __ bpm is bradycardia - This occurs normally in well-trained athletes whose heart muscle develops along with skeletal muscles

60

For which features should the nurse inspect during assessment of the sclera? Visual acuity Corneal abrasions Color of the sclera Eyelid fasciculations Presence of senile hyaline plaque

Color of the sclera Presence of senile hyaline plaque

Very sensitive to touch; contact with a wisp of cotton stimulates a blink in both eyes, called ___________ reflex A. Pupillary B. Corneal C. Blinking D. Symmetrical

Corneal

The healthcare provider palpates the prostate gland and seminal vesicles with the patient standing as part of which element of the examination? Spinal Rectal Neurologic Abdominal/Genital

Abdominal/Genital

Once you can recognize normal sounds, you can distinguish the __________ sounds and "extra" sounds!! A. Abnormal B. Irregular C. Weird D. Unusual

Abnormal

The adaptation of eye for near vision is called: A. Focus B. Accommodation C. Near sightedness D. Reflexive ability

Accommodation

______ ________, or a white, grey, or blue opaque ring in the corneal margin is commonly seen around cornea in aging adults. A. Aurora borealis B. Diabetic Retinopathy C Arcus senilis D. Strabismus fatalis

Arcus senilis

When axillary route used, place tip well into ______, and hold child's arm close to body A. Mouth B. Rectum C. Armpit D. Ear

Armpit

Which suture is present in between the frontal and parietal lobes? Multiple choice question Coronal Sagittal Lamboidal Squamosal

Coronal

The registered nurse teaches a student nurse how to palpate the thyroid gland of a patient. Which action by the student nurse would indicate a need for further teaching? Asking the patient to lie in the side lying position Giving a glass of water to the patient during palpation Tilting the head back to stretch the skin against the thyroid Using the fingers of the left hand to push the trachea slightly to the right

Asking the patient to lie in the side lying position

Place the examination components in order for the adult patient who is supine. Palpate for pedal edema Auscultate heart Percuss liver border Inspect abdomen

Auscultate heart Inspect abdomen Percuss liver border Palpate for pedal edema

__________ temperature is safe and accurate for infants and young children when environment is reasonably controlled A. Rectal B. Oral C. Axillary D. Temporal

Axillary

Senile tremors are ________ and include head nodding and tongue protrusion A. Malignant B. Benign C. Tender D. Normal

Benign

Clumping of proteins in the lens forms: A. Tumors B. Cataracts C. Cysts D. Glaucoma

Cataracts

Which features of the buccal mucosa should be inspected as part of a thorough ear, nose, and throat examination? Color Masses Swelling Symmetry Ulcerations

Color Swelling Symmetry Ulcerations

_____ ________________ is an inherited recessive X-linked trait, and is rare in _________

Color blindness, females

The nurse is caring for an infant born using forceps delivery. On examination, the nurse finds that the infant's head tilts to one side with limited neck rotation range of motion (ROM) to the opposite side. Which cranial nerve does the nurse expect to be damaged? Cranial nerve I Cranial nerve VII Cranial nerve VIII Cranial nerve XI

Cranial nerve XI. Cranial nerve XI innervates the sternomastoid muscle of the neck. Therefore, the nurse suspects injury to cranial nerve XI.

When inspecting the nasal septum, which features would the nurse assess? Crusting Bleeding Alignment Perforation Tenderness

Crusting Bleeding Alignment Perforation

With infant, reverse order of vital sign measurement to respiration, pulse, and temperature A. Temperature, respiration, pulse B. Pulse, temperature, respiration C. Pulse, respiration, temperature D. Respiration, pulse, temperature

D. Respiration, pulse, temperature

In ______ __________ patients, you normally may see small brown macules (like freckles) on sclera, which should not be confused with foreign bodies or petechiae A. Diabetes Mellitus B. Dark-Skinned C. Macular Degeneration D. Aged Adult

Dark-skinned

Which elements should be performed after light palpation of all quadrants of the abdomen in the adult patient? Percussion of all quadrants Auscultation for bowel sounds Deep palpation of all quadrants Inspection of abdominal contour

Deep palpation of all quadrants

Central acuity may decrease, particularly after 70 years of age; peripheral vision may be _____________

Diminished

Subjective data may include pain, redness, swelling, and: A Fatigue B. Floaters C. Diplopia (double vision) D. Itching

Diplopia (double vision)

What does it mean if a patient has conductive hearing loss? A. Punctured eardrum B. Ear infection C. Inner ear is damaged D. CN 8 is not working right

Ear infection

For which features should the nurse inspect the orbital area? Edema Puffiness Tenderness Temperature Sagging tissue

Edema Puffiness Sagging tissue

Allows equalization of air pressure on each side of TM so that it does not rupture

Eustachian tube

Opening that connects middle ear with nasopharynx and allows passage of air

Eustachian tube

On which elements should the nurse focus when performing the physical examination component of the functional assessment? Determining caregiver's abilities Evaluating coordination and gait Assessing for dyspnea with exertion Asking about use of a cane or walker Measuring blood pressure while the patient is seated and standing

Evaluating coordination and gait Assessing for dyspnea with exertion Measuring blood pressure while the patient is seated and standing

Transillumination is a technique used to assess the head of infants under which circumstances? The infant has a neck mass. The infant's oral mucosa appears dry. The infant has suspected intracranial lesions. The infant has suspected respiratory compromise. The infant has a rapidly increasing head circumference.

The infant has suspected intracranial lesions. The infant has a rapidly increasing head circumference.

The nurse is assessing a patient who has an acute infection and enlarged lymph nodes. Which assessment finding would the nurse expect? Multiple choice question The lymph nodes are enlarged, firm, nontender, and mobile. The lymph nodes are painless, rubbery, and discrete. The lymph nodes are warm, tender, and firm, but freely movable. The lymph nodes are hard, longer than 3 cm, nontender, and fixed.

The lymph nodes are warm, tender, and firm, but freely movable.

In some aging adults, a mild rhythmic _________ of the head may be normal A. Nodding B. Banging C. Shaking D. Tremor

Tremor

Physical growth is perhaps best index of a child's general health A.

True

What is the single most important step to decrease microorganism transmission?

Wash hands, gel in and gel out

In which ways could the nurse evaluate a young child's hearing? Use the Snellen E chart or HOVT chart Whisper words with meaning to the child Have the child repeat phrases the nurse yells Inspect the tympanic membrane for perforations

Whisper words with meaning to the child Ask the child to perform tasks using a soft voice

Soft, raised yellow plaques occurring on lids at inner canthus are called: A. eye crusties B. corneal discharge C. Oscillopsia D. Xanthelasma

Xanthelasma

Respirations - Watch infant's ____________ for movement, because infant's respirations normally more diaphragmatic than thoracic A. chest B. abdomen C. throat D. nose

abdomen

Normal pathway of hearing is

air conduction (AC)

Alternate route is by (BC)

bone conduction (used tuning fork)

Cornea may look _________ with age

cloudy

Ask the patient about their self-care behaviors, including environmental ______________ at home or at work that may affect your eyes? If so, do you wear __________

conditions, goggles

For infants and children, count pulse for _________ ______ to take into account normal irregularities, such as sinus arrhythmia A. fifteen seconds B. full minute C. thirty seconds D. two minutes

full minute

If retinal vessels are dilated or hemorrhaging, it can be useful for detecting _________ and ______ __________

hypertension, diabetes mellitus

Lymphatic drainage of external ear flows to _________, ___________, and __________ ________ nodes

parotid, mastoid, and superficial cervical

When inspecting anterior eyeball structures, eyeballs should be aligned normally in their sockets with no ___________ or sunken appearance

protrusion

Wash hands after -

removing gloves

When counting ____________, instead, maintain your position of counting radial pulse and unobtrusively count

respirations

The visual receptive layer of eye where light waves changed into nerve impulses A. Retina B. Cornea C. Optic Disc D. Macula

retina

Extraocular muscle function, and testing for ______________ (squint, crossed eye) is important screening measure during early childhood A. Amblyopia. B. Refractive errors C. Strabismus D. Cataracts

strabismus

Eyes may appear as _________ from atrophy of orbital fat A. sunken B. dull C. bulging D. tired

sunken

Eustachian tube is normally closed, but opens with _____________ or _____________

swallowing, yawning