Health Assessment Exam 2 Chapters 12-15
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
Auscultate with the bell over the lateral lobes
A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse appraised the client's eye alignment in which way?
By comparing the reflection of the light on the client's eye surface
A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?
"Have you taken any antibiotics in the past few weeks?"
A client asks why cerumen is important, stating, "It just clogs up the ears anyway." How should the nurse best respond?
"It helps to keep the ear drum soft and functioning well."
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?
A smoking cessation program
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?
Assess the client's blood pressure
What does the nurse assess the face for?
Asymmetry, Edema, Involuntary movements
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 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 vertebrae?
C7
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?
Conjunctiva
A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?
Document this as an expected assessment finding
A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement?
Headache Impact Test
A client presents to the health care clinic with reports of a 12-pound unintentional weight loss despite being hungry all the time, profuse sweating, and swelling around the anterior neck area. The client states that she does not have insurance and cannot afford to see a regular health care provider. What nursing diagnosis can the nurse confirm from this data?
Health Seeking Behaviors
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location?
Inferior to the mandible beneath the tongue
A nurse is presenting a class to a local community 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?
Involves light rays striking the retina
The nurse is reviewing a client's electronic health record before assessing her mouth. Which diagnosis would the nurse recognize as an indication for immediate medical follow-up?
Leukoplakia
The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?
Notify the healthcare provider about the finding.
A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique?
Percussion
An adult farm worker presents at the ED after falling out of a hay loft. The client states falling approximately 4 hours ago and did not lose consciousness. The client is experiencing only a mild headache. When asked why the client came to the ED, the client states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse?
Possible basilar skull fracture
A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for ne328xt?
Range of motion of the neck
Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?
Red, bleeding
The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion?
Redness and bulging of the eardrum
Which of the following tests use a tuning fork between two positions to assess hearing?
Rinne
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?
She can see at 20 feet what a normal person could see at 100 feet.
The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?
Skin cancer prevention
In examining a client's mouth with a penlight, the nurse notices salivary ducts that are visible on the buccal mucosa across from the second upper molars. The nurse recognizes these as which of the following?
Stenson's ducts
The client comes to the clinic with complaints of a sore throat, difficulty swallowing, malaise, and anorexia. Upon examination, the nurse notes a red throat with enlargement of the tonsils and jaw and neck lymph nodes. Which condition does the nurse suspect the client has?
Strep throat
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 client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?
There is no reaction in the opposite pupil to light.
A client diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?
Tinnitus
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
A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?
Torus palatinus
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina?
Transforms light rays into nerve impulses that are conducted to the brain
Which portion of the middle ear equalizes pressure?
Tympanic membrane
A nurse is teaching about hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend?
Washing with a warm, moist washcloth
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
The nurse notes a brown hairy coating on the tongue when assessing the oral cavity of the client. Which medication would the nurse suspect as the causative agent when reviewing the client's medications?
amoxicillin (Amoxil)
A client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the nurse suspect is occurring with this client?
conjunctivitis
A nurse is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding?
consensual reflexes observed
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
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?
preauricular
A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should
refer the client to an optometrist.
A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders?
tic douloureux
A nurse inspects the gums and teeth of a middle-aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?
"Are you experiencing any tooth pain?"
A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?
"Hormones affect the severity of migraine headaches."
The nurse is assessing the head and neck of a 51-year-old 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?
Auscultate the client's thyroid.
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?
Cranial nerve VII
A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding?
goiter
