Health Assessment Exam 3

The parotid gland's duct that opens into the mouth opposite the second molar is: A. the Wharton duct. B. the salivary duct. C. Stensen duct. D. the sublingual duct.

C. Stensen duct. The parotid gland's duct is the Stensen duct; it runs forward to open on the buccal mucosa opposite the second molar.

The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding for the aging adult? A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membrane

ANS: A A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: A)dehydration. B) irritation by gastric juices. C) a normal oral assessment. D) side effects from nausea medication.

ANS: A Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

The salivary gland that is the largest and located in the cheek in front of the ear is the _____ gland. A) parotid B) Stensen's C) sublingual D) submandibular

ANS: A The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensen's duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw.

The nurse is doing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? A)"Are you aware of having any allergies?" B) "Do you have an elevated temperature?" C) "Have you had any symptoms of a cold?" D)"Have you been having frequent nosebleeds?"

ANS: A With chronic allergy, mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: A) light pink with a slight bulge. B) pearly gray and slightly concave. C) pulled in at the base of the cone of light. D)whitish with a small fleck of light in the superior portion.

ANS: B Rationale: The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

The primary purpose of the ciliated mucous membrane in the nose is to: A) warm the inhaled air. B) filter out dust and bacteria. C) filter coarse particles from inhaled air. D) facilitate movement of air through the nares.

ANS: B The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? A) No sensation B) Firm pressure C) Pain during palpation D) Pain sensation behind eyes

ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies and acute infection (sinusitis).

In performing a whispered words test to assess hearing, which of these actions would the nurse do? A) Shield the lips so that the sound is muffled. B) Whisper a set of random numbers and letters and ask the patient to repeat them. C) Ask the patient to place his finger in his ear to occlude outside noise. D)Stand about 4 feet away to ensure that the patient can really hear at this distance.

ANS: B With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly a set of random numbers and letters, such as "5, B, 6." Normally, the person repeats each number and letter correctly after you say it.

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? A)"We will need to get a biopsy and see what the cause is." B)"This is an overgrowth of hair and will go away in a few days." C)"This is a fungal infection caused by all the antibiotics you've received." D)"This is probably caused by the same bacteria you had in your lungs."

ANS: C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus.

An 18-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of these findings would be consistent with an acute infection? A)Tonsils 1+/1-4+ and pink, same color as oral mucosa B)Tonsils 2+/1-4+ with small plugs of white debris C)Tonsils 3+/1-4+ with large white spots D)Tonsils 3+/1-4+ with pale coloring

ANS: C Rationale With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? A) Sticky honey-colored cerumen is a sign of infection. B) The presence of cerumen is indicative of poor hygiene. C) The purpose of cerumen is to protect and lubricate the ear. D) Cerumen is necessary for transmitting sound through the auditory canal.

ANS: C The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? A) Hypertrophy of the gums B) An increased production of saliva C) A decreased ability to identify odors D) Finer and less prominent nasal hair

ANS: C The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and there is a decrease in saliva production.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? A) "Do you ever notice ringing or crackling in your ears?" B) "When was the last time you had your hearing checked?" C) "Have you ever been told you have any type of hearing loss?" D) "Was there any relationship between the ear pain and the discharge you mentioned?"

ANS: D Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

Clonus that may be seen when testing deep tendon reflexes is characterized by a(n): A. additional contraction of the muscle that is of greater intensity than the first. B. set of rapid, rhythmic contractions of the same muscle. C. parallel response in the opposite extremity. D. contraction of the muscle that appears after the tendon is hit the second time.

B. set of rapid, rhythmic contractions of the same muscle. Clonus is a set of rapid, rhythmic contractions of the same muscle.

Which of the following questions would the examiner ask to determine whether an individual has epistaxis? A. "Do you have any difficulty with swallowing?" B. "Have you ever noticed any unusual lesions on the inside of your mouth?" C. "Do you experience nose bleeds?" D. "Do you experience a runny nose frequently?"

C. "Do you experience nose bleeds?" Epistaxis is the medical term for a nose bleed. D. "Do you experience a runny nose frequently?"

What term is used to describe involuntary muscle movements? A. Ataxia B. Flaccidity C. Athetosis D. Vestibular function

C. Athetosis Athetosis is slow, writhing, continuous, and involuntary movements of the extremities.

What term is used to describe involuntary muscle movements? A. Ataxia B. Flaccidity C. Athetosis D. Vestibular function

C. Athetosis Athetosis is slow, writhing, continuous, and involuntary movements of the extremities.

A 64 YEAR OLD FEMALE PATIENT CALLS OUT TO THE NURSE STATING, "I SEE SPIDERS ON MY ARM." THE NURSE SUSPECTS THE PATIENT IS DISPLAYING SYMPTOMS OF DELIRIUM. WHICH TOOL WOULD BE MOST APPROPRIATE FOR THE NURSE TO USE WITH THIS PATIENT? A) Glasgow Coma Scale B) Neurologic recheck examination C) Confusion Assessment Method (CAM) D) Complete neurologic examination

Correct answer is C. The Confusion Assessment Method (CAM) is used to assess for delirium. Delirium is an acute confusional state characterized by disordered thinking and perceptions, inattention, incoherent conversation, disorientation, and is often accompanied by agitation and visual hallucinations.

A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. A)Low gurgling; bell B) Loud, whooshing, blowing; diaphragm C) Soft, whooshing, pulsatile; bell D)High-pitched tinkling; diaphragm

Correct answer is C: a bruit is a soft, whooshing, pulsatile sound that is best assessed with the bell of the stethescope.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe. A) frontal B) parietal C) occipital D) temporal

The correct answer is A. The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.

When completing a health assessment of an older adult with mobility problems, the sequence should: A. begin with the physical examination followed by the health history. B. be from head to toe to prevent missing any important assessments. C. be arranged to minimize the number of position changes for the patient and the examiner. D. start with the most invasive assessments.

C. be arranged to minimize the number of position changes for the patient and the examiner. If the older adult patient has limited mobility, the examiner should arrange the sequence to minimize the number of position changes for the patient.

When examining a patient's cranial nerve (CN) function, the nurse remembers that the muscles in the neck that are innervated by CN XI( Spinal Accessory) are the: A)sternomastoid and trapezius. B)spinal accessory and omohyoid. C)trapezius and sternomandibular. D)sternomandibular and spinal accessory.

Correct Answer is A The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: A) consider this a normal finding. B) refer the individual for further evaluation. C) document this as an asymmetric light reflex. D) perform the confrontation test to validate the findings.

Correct Answer: A Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check the extraocular eye muscles. The nurse knows that a healthy finding would be: A. Each eye moves in opposite directions from each other B. There is parallel tracking of the object with both eyes. C. A rapid eye blink is expected. D. The light reflex of the eyes is located in the same position in each eye.

Correct Answer: B A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

The nurse is assessing the pupils of a patient with a pen light. Which finding would be considered normal? A)Both eyes cross when exposed to the light. B)The patient's pupils are fixed and dilated in response to light. C)Both pupils dilate in response to light. D)Both pupils constrict in response to light.

Correct Answer: D The pupils should constrict in response to light.

The nurse is assessing the ear of an adult. How should the nurse perform the examination? A. Pull the pinna down and insert scope B. Insert the scope straight into the ear C. Pull the pinna up and back and insert the scope D. Tilt the scope to the angle of the ear

The correct answer is C: Pull the pinna up and back and insert the scope. Rationale Pulling the pinna up and back on an adult helps to straighten the S-shape of the canal.

During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as: A) vertigo. B) syncope. C) dizziness. D) seizure activity.

The correct answer is A. True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Dizziness is a lightheaded, swimming sensation. Syncope is a sudden loss of strength or a temporary loss of consciousness. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances

When assessing the teeth and gums, which of the following would be a normal finding? A. The teeth are white and the gums are coral pink B. The gums are bleeding C. The adult patient has 22 total teeth D. The upper and lower jaw are not aligned

The correct answer is A. The normal finding would be the teeth are white and the gums are coral pink. The other answers would be considered abnormal findings.

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient: A) demonstrates ability to hear normal conversation. B) sticks tongue out midline without tremors or deviation. C) follows an object with eyes without nystagmus or strabismus. D) moves the head and shoulders against resistance with equal strength.

The correct answer is D. These are the expected normal findings when testing cranial nerve XI (spinal accessory nerve): The patient should demonstrate the ability to rotate the head both ways forcibly against resistance applied to the side of the chin with equal strength and shrug the shoulders against resistance with equal strength on both sides.

YOU ARE CARING FOR A 20 YEAR-OLD FEMALE PATIENT ADMITTED WITH C/O DIZZINESS. WHAT QUESTIONS ARE APPROPRIATE TO ASK THE PATIENT TO ELICIT HEALTH HISTORY INFORMATION REGARDING HER NEURO SYSTEM? A) Do you experience weakness? B) Do you experience numbness or tingling? C) Have you encountered any environmental or occupational hazards? D) All the above

The correct answer is D. These are all questions you want to ask a patient to elicit information about their health history. A patient reporting dizziness may have other symptoms. The more information you elicit helps to plan treatment for the patient.

A 26 year old female patient comes in to the clinic complaining of perianal itching. Which of the following would NOT be appropriate to assist this patient in preparing for a perianal examination? A) Instruct the patient to inform you of any pain or discomfort during the exam. B) Assume that the patient has had a vaginal exam before and has no questions. C) Ask the patient if she would like a family member, friend or chaperone present. D) Have the patient empty her bladder.

correct answer B. To prepare for the exam and to help the patient relax, reduce anxiety, and retain some sense of control, you want to make sure that the client has an empty bladder; positioned so her perineum or private area is not exposed to an inadvertent open door, ask if she wants a family member, friend or chaperone present; ask the patient to tell you if they experience pain or discomfort during the exam; and explain each step of the examination before you begin and the purpose of the exam.

A 75 year old patient with an enlarged prostate is concerned because he has trouble sleeping. He states, "I have to pee about 6 or 7 times a night and it just drips." What is the most appropriate response for the nurse to make? A) "You probably have a bladder infection. We'll need to give you antibiotics." B) This is a natural part of the aging process." C) "This is the way the kidney removes bacteria from the body." D) "You may want to cut back on drinking fluids about 3 hours before bedtime."

correct answer is D. Nocturia may be caused by diuretic medication, habit, or fluid ingestion 3 hours before bedtime, coffee and alcohol especially have a diuretic effect. If the man already has an enlarged prostate, it is important to limit fluid intake at bedtime within 3-4 hours of bedtime to reduce the incidence of nocturia which is urinary frequency at night.

A NURSE SUSPECTS THAT HER PATIENT MAY HAVE SUFFERED A STROKE. WHICH TOOLS ARE APPROPRIATE FOR THE NURSE TO USE TO CONFIRM HER SUSPICIONS? A) R.A.C.E B) NIH Scale C) F.A.S.T D) Both B and C

correct answer is D. The two tools used to assess strokes are F.A.S.T and the NIH Stroke Scale. RACE is the acronym that helps staff remember the proper steps when responding to a fire emergency.

A NURSE IS CONDUCTING A COMPLETE NEUROLOGICAL EXAM ON A PATIENT WHO REPORTS DIFFICULTY WITH SPEECH. WHAT OTHER QUESTIONS WOULD BE MOST APPROPRIATE FOR THE NURSE TO ASK THIS PATIENT? A) When did you first notice this? B) How long did it last? C) Can you describe the symptoms? D) All of the above

correct answer is D. These are all questions you want to ask a patient reporting speech difficulty. Dysarthria is difficulty forming words. Dysphasia is difficulty with language comprehension or expression. You also want to note other symptoms such as if they have trouble forming words or saying something unintended.

During the interview, a patient reveals that she has been having a large amount of vaginal discharge and itching. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"

the correct answer is C. Normal vaginal discharge is small, clear, or cloudy but nonirritating. A large amount which is foul-smelling suggests vaginal infection. With discharge, it is important to note the character (foul-smelling) and color (white, yellow-green, gray, curd-like). A rash is a result of irritation from discharge.

A nurse is providing a patient with information on anal and rectal health. This should include which of the following? A) Avoid straining during defecation B) Eat a high fiber diet C) Avoid lifting extremely heavy items D) All the above

the correct answer is D. Tips to promote rectal and anal health include: Eating a high fiber diet; keeping the anal area clean and dry; avoid scratching the anus; avoid putting objects in the anus that do not belong there; avoid straining during defecation; and avoid lifting extremely heavy items: furniture, patients, etc.

The external structure of the ear is identified as the: A. auricle. B. atrium. C. aureole. D. auriga.

A. auricle.

Upon palpation the prostate gland is enlarged, nontender, firm and smooth with a palpable central groove. This assessment finding indicates: A. benign prostatic hypertrophy. B. prostatitis. Incorrect C. prostate carcinoma. D. a normal prostate gland.

A. benign prostatic hypertrophy. In benign prostatic hypertrophy, the prostate gland is enlarged, nontender, firm and smooth with a palpable central groove.

Which of the following documentation statements indicates a normal assessment of the perianal area? A. "Anus moist, color darker than adjacent tissues. No lesions or discharge. Opening tightly closed." B. "Anal area dark pink, moist, with 0.5-cm shiny blue skin sac at 5 o'clock." C."Anus with flabby skin sac at 7 o'clock." D."Small round opening in the anal area."

A. "Anus moist, color darker than adjacent tissues. No lesions or discharge. Opening tightly closed." Normal findings during inspected of the perianal area include: anus moist and hairless, with coarse folded skin that is more pigmented than the perianal skin; anal opening is tightly closed; no lesions present.

Which of the following patients should the nurse assess first? A. A 48-year-old patient with shortness of breath and pulse oximeter reading of 88% B. A 52-year-old patient with a white blood cell count of 22,000 cells/mm3 C. A 59-year-old patient with chest pain that increases with deep inspiration D. An 89-year-old patient with a urinary tract infection who is confused

A. A 48-year-old patient with shortness of breath and pulse oximeter reading of 88% The nurse should use the ABC's to determine which order to assess the patients. The nurse should assess the 48-year-old patient with respiratory problems first (shortness of breath and pulse oximeter reading of 88%).

The examiner notices a fine tremor when the patient sticks out his or her tongue. What disorder is consistent with this finding? A. Hyperthyroidism B. Diabetic ketoacidosis C. Halitosis D. Alcoholism

A. Hyperthyroidism A fine tremor of the tongue occurs with hyperthyroidism.

What is an advantage for using SBAR during staff communication? A. Improves verbal communication and reduces medical errors B. Provides a complete patient health history C. Focuses on a comprehensive physical examination D. Avoids making recommendations

A. Improves verbal communication and reduces medical errors SBAR improves verbal communication and reduces medical errors.

The nurse is calling the health care provider about a patient's changing condition. Which of the following would be included in the SBAR communication? A. Situation, Background, Assessment, and Recommendation SBAR communication stands for Situation, Background, Assessment, and Recommendation. B. Subjective information, Background, Assessment, and Revisions needed C. Situation, Background, All vitals, and Review of orders D. Summary, Better plan, Accurate diagnosis, and Rights

A. Situation, Background, Assessment, and Recommendation SBAR communication stands for Situation, Background, Assessment, and Recommendation.

On examination of an American Indian's mouth, the examiner notices the presence of a bifid uvula. How should this finding be interpreted? A. This is an expected variation associated with this individual. B. This condition is frequently associated with cleft palate. C. This may indicate the presence of oral cancer. D. This is rare and indicates other congenital anomalies may be present.

A. This is an expected variation associated with this individual. Bifid uvula is a condition in which the uvula is split either completely or partially. This condition occurs in 18% of some American Indian groups.

What is the major cause of decreased saliva production in the older adult? A. Use of anticholinergic medications B. Normal aging process Incorrect C. Decreased fluid intake D. A diminished sense of taste and smell

A. Use of anticholinergic medications The major cause of decreased saliva flow is the use of medications that have anticholinergic effects.

Unlicensed assistive personnel can: A. ambulate a patient with lower extremity weakness. B. detect adventitious breath sounds. C. observe a change in skin lesion quality. D. assess for electrolyte imbalances.

A. ambulate a patient with lower extremity weakness. Unlicensed assistive personnel can assist a patient with activities of daily living such as ambulation.

Pruritus is the presence of: A. an itching or burning sensation. B. a longitudinal tear in the superficial mucosa at the anal margin. C. blood in the stool. D. excessive fat in the stool.

A. an itching or burning sensation. Pruritus is an itching or burning sensation.

During auscultation of breath sounds, the examiner should: A. compare sounds on the left and right side. B. listen with the bell of the stethoscope. C. instruct the patient to breathe in and out through the nose. D. only listen to the posterior chest for adventitious sounds.

A. compare sounds on the left and right side. The examiner should auscultate the lungs from side to side to compare the breath sounds.

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a: A. dermatome. B. dermal segmentation. C. dermal hemisphere. D. crossed representation.

A. dermatome. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve.

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a: A. dermatome. B. dermal segmentation. C. hemisphere. D. crossed representation.

A. dermatome. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve.

The first sign of puberty in males is: A. enlargement of the testes. Correct B. the appearance of pubic hair. Incorrect C. an increase in penis size. D. pubic hair growth extending up the abdomen.

A. enlargement of the testes. The first sign of puberty in males is the enlargement of the testes.

The position of the tympanic membrane in the neonate is more ________________, making it more difficult to visualize with the otoscope. A. horizontal B. vertical C. perpendicular D. oblique

A. horizontal The position of the eardrum is more horizontal in the neonate, making it more difficult to see completely and harder to differentiate from the canal wall.

The presence of primitive reflexes in a newborn infant is indicative of: A. immaturity of the nervous system. B. prematurity of the infant. C. mental retardation. D. spinal cord alterations.

A. immaturity of the nervous system. The nervous system is not completely developed at birth, and motor activity in the newborn is under the control of the spinal cord and medulla. The neurons are not yet myelinated. Movements are directed primarily by primitive reflexes. As the cerebral cortex develops during the first year, it inhibits these reflexes, and they disappear at predictable times. Persistence of the primitive reflexes is an indication of central nervous system dysfunction.

The examiner should auscultate for carotid bruits if the patient: A. is middle-aged or older. B. is pregnant and has gestational diabetes. C. complains of abdominal pain. D. has enlarged, tender cervical lymph nodes.

A. is middle-aged or older. The examiner should auscultate for carotid bruits if the patient is middle-aged or older or shows symptoms or signs of cardiovascular disease .

One of the purposes of the paranasal sinuses is to: A. lighten the weight of the skull bones. B. warm and moisten the inspired air. Incorrect C. amplify sound. D. augment the sensory sensation of smell.

A. lighten the weight of the skull bones. The paranasal sinuses lighten the weight of the skull bones.

An 80-year-old patient admitted with chest pain is on a monitored unit. The hearing for this patient should initially be assessed by: A. normal conversation. B. tuning fork tests. C. the whispered voice test. D. audiometric testing.

A. normal conversation. During the first contact with the patient (general survey or appearance), the nurse should assess the patient's ability to hear a normal tone of voice. If the patient is not able to hear a normal tone of voice, further testing may be indicated such as the whispered voice test or audiometric testing.

Automatic associated movements of the body are under the control and regulation of: A. the basal ganglia. B. the thalamus. C. the hypothalamus. D. Wernicke's area.

A. the basal ganglia. The basal ganglia controls automatic associated movements of the body.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: A) auricle. B) concha. C) outer meatus. D)mastoid process.

ANS: A Rationale The external ear is called the auricle or pinna and consists of movable cartilage and skin.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? A) It is the normal pathway for hearing. B) It is caused by the vibrations of bones in the skull. C) The amplitude of sound determines the pitch that is heard. D) A loss of air conduction is called a conductive hearing loss.

ANS: A The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? A) Using gentle pressure, palpate with both hands to compare the two sides. B) Using strong pressure, palpate with both hands to compare the two sides. C) Gently pinch each node between one's thumb and forefinger and move down the neck muscle. D)Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

ANS: A Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, to compare the two sides symmetrically

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: A) speak loudly so he can hear the questions. B) assess for middle ear infection as a possible cause. C) ask the patient what medications he is currently taking. D) look for the source of the obstruction in the external ear.

ANS: C A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: A) maintain balance. B) interpret sounds as they enter the ear. C) conduct vibrations of sounds to the inner ear. D) increase amplitude of sound for the inner ear to function.

ANS: C Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? A) Epistaxis B) Rhinorrhea C) Dysphagia D) Xerostomia

ANS: C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose; epistaxis is a bloody nose. Xerostomia is a dry mouth.

Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X (vagus)? A)Observe the patient's ability to articulate specific words. B)Observe the patient's ability to move the shoulders against resistance. C)Have the patient stick out the tongue and observe for tremors or pulling to one side. D)Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

ANS: D Ask the person to say "ahhh" and note that the soft palate and uvula rise in the midline. This tests one function of CN X, the vagus nerve. Cranial nerve X (vagus) can also be tested by eliciting the gag reflex, as well as CN IX (glossopharyngeal). Cranial nerve XII (hypoglossal) is tested by asking the patient to stick out his or her tongue and CN XI (spinal accessory) is tested by neck ROM and shoulder movement against resistance.

The nurse administers an intravenous dose of pain medication. The nurse should reassess the patient in: A. 5 minutes. B. 15 minutes. C. 30 minutes. D. 60 minutes.

B. 15 minutes

A hospitalized patient has pneumonia. Which of the following assessments would not be indicated in this patient? A. Swallowing assessment B. Assessment of passive range of motion C. Cardiac auscultation D. Pain assessment

B. Assessment of passive range of motion The nurse would not assess passive range of motion; the nurse should assess the patient's ability to turn in bed, dangle at the bedside, sit in a chair, and ambulate. In addition, the nurse should assess the patient's need for any ambulatory aids or equipment and the patient's risk for falling.

The _____________ coordinates movement, maintains equilibrium, and helps maintain posture. A. extrapyramidal system B. cerebellum C. upper and lower motor neurons D. basal ganglia

B. Cerebellum The cerebellum controls motor coordination of voluntary movements, equilibrium (i.e., the posture balance of the body), and muscle tone.

Which of the following behaviors demonstrated by an individual may be indicative of hearing loss? A. Not looking at the examiner when being questioned B. Frequently asking for the question to be repeated . C. Talking in a high-pitched voice D. Speaking slowly with well-articulated consonants

B. Frequently asking for the question to be repeated

Which of the following pairs of sinuses is absent at birth, is fairly well developed between 7 and 8 years of age, and is fully developed after puberty? A. Maxillary B. Frontal C. Sphenoid D. Ethmoid

B. Frontal The frontal sinuses are absent at birth, are fairly well developed between 7 and 8 years of age, and reach full size after puberty.

Binaural interaction at the level of the brain stem permits: A. interpretation of sound. B. identification and location of the direction of the sound. C. amplification of sound. D. direction of sound toward the appropriate conduction pathway.

B. Identification and location of the direction of the sound.

When assessing the hypoglossal nerve (CN XII), the nurse looks at and tests: A. full, sustained eye opening B. Movement and strength of the tongue. C. The uvula rising to the midline when a person says, "Ah." D. Symmetry of facial feature

B. Movement and strength of the tongue

The hospitalized patient does not require a full neurologic examination during every shift assessment. Which of the following may be a way of assessing the neurologic status of the hospitalized patient? A. Palpate the carotid pulse. B. Offer the client a glass of water. C. Look at the significant other throughout the examination. D. Assign the nursing assistant to ask the patient questions and report the findings.

B. Offer the client a glass of water. Offering the patient water is not only a courtesy but also it is an opportunity for the nurse to note the physical data: the person's ability to hear, follow directions, cross the midline, and swallow.

The area of the brain that controls personality, behavior, emotions, and intellectual function is: A. Broca's area B. The frontal lobe C. Wernicke's area D. the temporal lobe

B. The frontal lobe

The nursing assistant takes the vital signs for the 12 patients on the unit. Who is responsible for interpreting the results? A. The nursing assistant should review the results for abnormalities. B. The registered nurse assigned to the patient(s) should interpret the vital signs. C. The charge nurse is responsible for reviewing the vital signs on all 12 patients. D. The unit manager must ensure that the nursing assistant reports any abnormal results.

B. The registered nurse assigned to the patient(s) should interpret the vital signs. The registered nurse assigned to the patient(s) is responsible for interpreting the results. The registered nurse is also responsible for delegating vital signs and for supervising the nursing assistant.

The ______ reflex is an example of a _________ reflex. A. plantar; deep tendon Incorrect B. abdominal; superficial C. quadriceps; pathologic D. corneal light; visceral

B. abdominal; superficial Superficial reflexes test the sensory receptor in the skin; the motor response is a localized muscle contraction. Superficial reflexes include abdominal, cremasteric, and plantar (or Babinski) reflexes.

Hematuria is a term used for: A. bloody discharge. B. blood in the urine. C. bleeding after intercourse. D. urine in the blood

B. blood in the urine. Hematuria is the term used to describe blood in the urine.

The _____________ coordinates movement, maintains equilibrium, and helps maintain posture. A. extrapyramidal system B. cerebellum C. upper and lower motor neurons D. basal ganglia

B. cerebellum The cerebellum controls motor coordination of voluntary movements, equilibrium (i.e., the posture balance of the body), and muscle tone.

Soft, pointed, fleshy papules that occur on the genitalia caused by the human papilloma virus (HPV) are known as: A. chancres. B. genital warts. C. urethritis. D. varicoceles.

B. genital warts. Condylomata acuminata (genital warts) are soft, pointed, fleshy papules that occur on the genitalia and are caused by the HPV.

Cessation of menses is known as: A. menarche. B. menopause. C. salpingitis. D. adnexa.

B. menopause. Menopause is the cessation of menses.

A patient is taking iron supplements. The patient should expect the stools to be: A. clay colored. B. nontarry and black. C. tarry and black. D. frothy.

B. nontarry and black. Iron medication supplements will cause stools to be nontarry and black.

Cerebellar function is tested by: A. muscle strength assessment. B. performance of rapid alternating movements. C. the Phalen maneuver. D. superficial pain and touch assessment.

B. performance of rapid alternating movements. The cerebellum controls motor coordination of voluntary movements, equilibrium, and muscle tone. Cerebellar function is tested by balance tests (e.g., gait, Romberg test) and coordination and skilled movements (e.g., rapid alternating movements, finger-to-finger test, finger-to-nose test, heel-to-shin test).

If the tympanic membrane has white dense areas, the examiner suspects: A. perforation from a ruptured membrane. B. scarring from recurrent ear infections. C. serous fluid from serous otitis media. D. a fungal infection.

B. scarring from recurrent ear infections. White dense areas indicate scarring on the tympanic membrane from recurrent ear infections.

Which of the following tests provides a precise quantitative measure of hearing? A. Tuning fork tests B. Romberg test C. Audiometer test D. Whispered voice test

C. Audiometer test An audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency.

An enlarged tongue (macroglossia) may accompany: A. cleft palate. B. hairy tongue. C. Down syndrome. D. fissured tongue.

C. Down syndrome. Macroglossia occurs with Down syndrome; it also occurs with cretinism, myxedema, and acromegaly. A transient swelling also occurs with local infections.

F.A.S.T. is an acronym used as a mnemonic to help detect and enhance responsiveness to stroke victim needs. The nurse recognizes that a correct interpretation of the acronym is: A. F = feel the face, A = arm yourself, S = stop, T=time to rest B. S.T.O.P. S=stop stroke, T=time to rest, O=opt out, P=poke to test C. F=face drooping, A=arm weakness, S=speech difficulty, T=time to call 911 D. none of the above.

C. F=face drooping, A=arm weakness, S=speech difficulty, T=time to call 911

During the assessment of extraocular movements, two back-and-forth oscillations of the eyes in the extreme lateral gaze occurs. This response indicates: A. that the individual needs to be referred for a more complete eye examination. B. a disease of the vestibular system and that should be evaluated. C. an expected movement of the eyes during this procedure. D. this assessment should be repeated in 15 minutes to allow the eyes to rest.

C. an expected movement of the eyes during this procedure. Nystagmus is a back-and-forth oscillation of the eyes. End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally.

The extrapyramidal system is located in the: A. hypothalamus. B. cerebellum. C. basal ganglia. D. medulla.

C. basal ganglia. The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system).

The nasal mucosa of an individual with rhinitis would be: A. moist and pink. B. swollen, boggy, and gray. C. bright red and swollen. D. pale with bright red bleeding.

C. bright red and swollen. The nasal mucosa is bright red and swollen with rhinitis.

The tympanic membrane of a child with acute otitis media would be: A. flat and slightly pulled in at the center. B. mobile and would flutter with the Valsalva maneuver. C. bulging with a distinct red color. D. shiny and translucent, with a pearly gray color.

C. bulging with a distinct red color. The tympanic membrane would be bulging and red with acute otitis media.

The most common sexually transmitted infection in the United States is: A. gonorrhea. B. syphilis. C. chlamydia. D. trichomoniasis.

C. chlamydia. Chlamydia is the most common sexually transmitted infection.

The examiner is assessing the extraocular muscles. Which of the following tests would be inappropriate? A. corneal light reflex B. six cardinal positions of gaze C. confrontation test D. cranial nerve III, IV, and VI testing

C. confrontation test The confrontation test assesses cranial nerve II and visual fields.

Long-term use of laxatives frequently leads to: A. hemorrhoids. B. a chronically inflamed gastrointestinal tract. C. dependence. D. fistula formation.

C. dependence. Long-term use of laxatives may lead to dependence.

The labyrinth of the inner ear is responsible for maintaining the body's: A. binaural interaction. B. air conduction. C. equilibrium. D. pressure equalization.

C. equilibrium. The labyrinth maintains the body's equilibrium.

An abnormal sensation of burning or tingling is best described as: A. paralysis. B. paresis. C. paresthesia. D. paraphasia.

C. paresthesia. Paresthesia is an abnormal sensation such as burning or tingling.

An abnormal sensation of burning or tingling is best described as: A. paralysis. B. paresis. C. paresthesia. D. paraphasia. .

C. paresthesia. Paresthesia is an abnormal sensation such as burning or tingling.

The patient sways and starts to fall when asked to stand with feet together and arms at sides with the eyes closed. This finding would be documented as a: A. positive Babinski sign. B. positive Ortolani sign. C. positive Romberg sign. D. positive modified Allen test.

C. positive Romberg sign. The Romberg test is an assessment of posture and balance (cerebellar function). Abnormal findings occur when the person sways, falls, or widens base of feet to avoid falling A positive Romberg sign is loss of balance that occurs when closing the eyes and occurs with cerebellar ataxia, loss of proprioception, and loss of vestibular function.

Testing the deep tendon reflexes gives the examiner information regarding the intactness of the: A. corticospinal tract. B. medulla. C. reflex arc at specific levels in the spinal cord. D. upper motor and lower motor neuron synaptic junction.

C. reflex arc at specific levels in the spinal cord. Measurement of the deep tendon reflexes reveals the intactness of the reflex arc at specific spinal levels.

Testing the deep tendon reflexes gives the examiner information regarding the intactness of the: A. corticospinal tract. B. medulla. C. reflex arc at specific levels in the spinal cord. D. upper motor and lower motor neuron synaptic junction.

C. reflex arc at specific levels in the spinal cord. Measurement of the deep tendon reflexes reveals the intactness of the reflex arc at specific spinal levels

The blood pressure readings for a 42-year-old male for the past two outpatient visits were 158/92 mm Hg and 146/94 mm Hg. The examiner would interpret the findings as: A. normal. B. prehypertension. C. stage 1 hypertension. Correct D. stage 2 hypertension.

C. stage 1 hypertension. Stage 1 hypertension is diagnosed with SBP between 140 and 159 mm Hg or DBP between 90 and 99 mm Hg.

Decreased estrogen levels during menopause cause: A. an enlargement of the uterus. B. pelvic muscles and ligaments to tighten. C. the ovaries to atrophy. D. the cervix to enlarge and turn blue.

C. the ovaries to atrophy. Decreased estrogen levels during menopause cause atrophy of the ovaries.

When an otoscope examination is performed on an older adult client, the tympanic membrane may be: A. pinker than that of a younger adult. B. thinner than that of a younger adult. C. whiter than that of a younger adult. D. more mobile than that of a younger adult.

C. whiter than that of a younger adult. During otoscopy the tympanic membrane of an older adult may be whiter in color than that of a younger adult. The tympanic membrane may also appear more opaque and dull.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____. A) XI; palpating the anterior and posterior triangles B) XI; asking the patient to shrug her shoulders against resistance C) XII; percussing the sternomastoid and submandibular neck muscles D) XII; assessing for a positive Romberg sign

Correct Answer: B The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. To test CN XI, we would have the patient perform neck ROM against resistance and shrugging the shoulders against resistance.

When assessing the pupillary light reflex, the nurse should use which technique? A) Shine a penlight from directly in front of the patient and inspect for pupillary constriction. B) Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. C) Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. D) Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.

Correct Answer: C To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: A) suspect that there is an opacity in the lens or cornea. B) check the light source of the ophthalmoscope to verify that it is functioning. C) consider this a normal reflection of the ophthalmoscope light off the inner retina. D) continue with the ophthalmoscopic examination and refer the patient for further evaluation.

Correct Answer: C The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: A) decreased in the elderly. B) impaired in a patient with cataracts. C) stimulated by cranial nerves I and II. D) stimulated by cranial nerves III, IV, and VI.

Correct Answer: D Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI. Cranial nerve III (oculomotor) controls the inferior oblique, superior rectus and inferior rectus eye muscles Cranial nerve IV (Trochlear) control the superior oblique eye muscle Cranial nerve VI (Abducens) controls them lateral rectus muscle

The nurse is assessing the patient's trachea. Which of the following would be a normal finding? A.The trachea rising to midline when the patient swallows B.The trachea deviating to the left when the person swallows C.The trachea deviating to the right when the person swallows D.The trachea not moving when the person swallows

Correct answer is A. The trachea should rise to the midline when the patient swallows. If it deviates to one side or the other that can indicate stroke or tumor.

A 45 YEAR OLD MALE WAS ADMITTED TO THE ED WITH SLURRED SPEECH. THE NURSE NOTES THAT THIS COULD BE DUE TO DYSFUNCTION OF WHAT CRANIAL NERVE(S)? A) Cranial Nerve I B) Cranial Nerve V C) Cranial Nerves IX and X D) Cranial Nerve III

Correct answer is C. Cranial Nerve IX (Glossopharyngeal): Motor function controls phonation and swallowing Cranial Nerve X (Vagus): Motor function controls talking and swallowing

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings? A) Thalamus B) Brainstem C) Cerebellum D) Extrapyramidal tract

Correct answer is C. The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the main relay station where sensory pathways of the spinal cord, cerebellum, and brainstem for synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

The nurse is assessing her patient's pupillary response to light. She moves her penlight in from the side of the patient's face into the right eye. Both the right and left pupil constrict. How would these reflexes be described? A) Right eye consensual response, left eye direct response B) Right eye medial response, left eye lateral response C) Right eye dilation response, left eye constricting response D) Right eye direct response, left eye consensual response

Correct answer is D: Right eye direct response, left eye consensual response Direct: Pupil size decreases (constricts) when exposed to a light source Consensual: The pupil on the opposing side constricts when the examiner shines a light source in the other eye

Which of the following subjective data would you want to collect for your patient when performing a Head, Face and Neck Exam? (Select all that apply) A. they have unusually frequent or severe headaches B. If they have any dizziness C. If they have any neck pain D. If they have any chest pain E. If they have any history of neck injury or surgery

Correct answers are A, B, C, E. Subjective data that you want to collect includes: Headache History of head injury, cosmetic or cranial surgery Dizziness Neck pain Noticed lumps or swelling History of neck injury or surgery

Which of the following children is at risk of recurrent otitis media? A. An 18-month-old infant who lives with a smoker. B. A 2-year-old child who has had two ear infections in the past 6 months. C. A 6-month-old infant who has a sibling who had tubes inserted at 3 years of age. D. An 18-month-old infant who has had three episodes of ear infections in a 5-month period.

D. An 18-month-old infant who has had three episodes of ear infections in a 5-month period. A first episode of otitis media (OM) that occurs within 3 months of life increases risk of recurrent OM. Recurrent OM is 3 episodes in past 3 months or 4 episodes within the past year.

A 40-year-old male patient has cellulitis of the left lower extremity and no history of health problems. Which of the following findings would need further evaluation? A. Calluses on both hands B. Receding hairline C. 2+ pedal pulses bilaterally D. Irregular pulse

D. Irregular pulse An irregular pulse is an abnormal finding and warrants further evaluation.

The first sign of puberty in girls is: A. the first menstrual cycle (menarche). B. axillary hair development. C. rapid increase in height. D. breast and pubic hair development.

D. breast and pubic hair development. The first signs of puberty are breast and pubic hair development, beginning between the ages of 8½ and 13 years. These signs usually occur together, but it is not abnormal if they do not develop together. This takes about 3 years to complete.

In addition to initiating digestion of food, saliva also: A. augments taste sensation. B. protects the mucosa from caustic substances. C. inhibits overgrowth of bacteria in the mouth. D. cleans and protects the mucosa.

D. cleans and protects the mucosa. Saliva moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa.

The Glascow Coma Scale (GCS) is used to measure all of the following functions except A. Eye opening B. Motor response C. Verbal response D. limb ataxia

D. limb ataxia

Dysmenorrhea is: A. painful intercourse. B. pain with defecation. C. pain with urination. D. pain associated with menstruation.

D. pain associated with menstruation. Dysmenorrhea is the abdominal cramping and pain associated with menstruation.

Which of the following would be considered subjective data? A. The patient states that he has clear discharge coming out of his ears. B. You note that the patient's ears are equal size and shape. C. The patient is unable to hear the words on the Whispered Voice Test. D. The patient's ear drum is a pearl gray color.

The correct answer is A. The rest of the answers are objective data.

The nurse is palpating the temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the tragus. Which of the following would be a normal finding? A) Nontender to palpation B) Crepitus C) The jaw locking D) Painful palpation

The correct answer is A: Nontender to palpation. When palpating the TMJ normal findings are smooth movement with no popping, crepitus, or tenderness.

The nurse is examining a male patient. The patient appears apprehensive. Which of the following actions are most appropriate to reduce the patient's anxiety? A) Use a soft, stroking touch B) Be confident and relaxed C) Talk to the patient about his sexual practices D) Perform the examination quickly

The correct answer is B. It is normal for the male to feel some apprehension about having his genitalia examined. As the examiner, it is important to: Accept these feelings and exhibit professionalism during the exam; discuss your concerns with a more experienced colleague; maintain a relaxed, unhurried, and business-like demeanor; avoid talking about the patient's genitourinary history or sexual practices during the exam; and use a firm, deliberate touch rather than a soft stroking one.

Which of these statements concerning areas of the brain is true? A) The cerebellum is the center for speech and emotions. B) The hypothalamus controls temperature and regulates sleep. C) The basal ganglia are responsible for controlling voluntary movements. D) Motor pathways of the spinal cord and brainstem synapse in the thalamus.

The correct answer is B. The hypothalamus is a vital area with many important functions: temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia controls autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not the thalamus.

The nurse is charting on a patient's eye assessment and notes PERRLA. What does this stand for? A. Pupils Equal, Rigid, React to Light, and Accessible B. Pupils Even, Right, React to Light, and Accomodation C. Pupils Equal, Round, React to Light and Accomodation D. Pupils Even, Rigid, Restrict from Light, and Accomodation

The correct answer is C Pupils Equal, Round, React to Light, and Accommodation

During the assessment of THE Biceps reflexes, the nurse finds that a patient's responses are normal bilaterally. The Nurse would be Correct in documenting this finding As ____+ A) 3+ B) 1+ C) 2+ D) 4+

The correct answer is C. Reflexes are graded 0 to 4 plus. 0 means no response, 1+ is diminished, and 2+ is normal, 3 + is brisk but is still probably normal. It may indicate disease, and 4+ is hyperactive with clonus.

The two sinuses that can be directly palpated are? A. Frontal and sphenoid B. Maxillary and ethmoid C. Frontal and maxillary D. Ethmoid and Sphenoid

The correct answer is C: Frontal and maxillary. The ethmoid and sphenoid sinuses are smaller and deeper and not accessible for examination.

The nurse is assessing a patient who has a hearing impairment. How should the nurse communicate with this patient?  A) Use a low tone and speak slowly. B) Use a normal tone of voice and speak slowly. C) Speak loudly with a normal rate. D) Face the patient and speak slowly.

The correct answer is D: Face the patient and speak slowly. Rationale When the patient is able to see your face they are better able to understand you. Speaking slowly ensures that they are able to understand and can ask you to repeat when necessary.

THE NURSE IS ASSESSING HER 40 YEAR OLD MALE PATIENT'S GAIT. AFTER ASSESSING HIS GAIT, SHE HAS THE PATIENT STAND WITH HIS EYES CLOSED TO PERFORM THE ROMBERG TEST IN ORDER TO ASSESS FUNCTION OF WHAT AREA OF HIS BODY? A) Cerebellum B) Temporal Lobe C) Spinal Cord D) Broca's Area

correct answer is A. To test cerebellar function, look at the person's gait when they walk. Another test that can be used is the Romberg test to assess balance. Have the person close their eyes while standing and stand close to catch the person in case he or she loses their balance.

ALL OF THE FOLLOWING ARE EXPECTED CHANGES THAT CAN BE SEEN IN THE OLDER ADULT DUE TO THE LOSS OF NEURONS IN THE BRAIN AND SPINAL CORD LIMITATION EXCEPT: A) Improvement in fine coordination and agility. B) Decreased muscle strength and agility. C) Decreased reaction time. D) Progressive decrease in cerebral blood flow.

correct answer is A. Aging can lead to general atrophy, steady loss of the neuron structure of the brain and spinal cord. One symptom is impaired fine coordination and agility, rather than improved. As a result, older adults can be at risk for falls and injury.

A nurse is performing an assessment on an uncircumcised male patient. She retracts the foreskin and remembers to return the skin to its original position in order to prevent all of the following except: A) An erection B) Tissue loss C) Decreased circulation D) Amputation

correct answer is A. Once you retract the foreskin, it is very important to return the foreskin to its original position after you're finished. Failure to return the foreskin to its original positon can cause trauma to the glans of the penis, decreased circulation resulting in tissue loss and possible amputation of some portion of the penis.

During an examination of a 62 year old male patient, the nurse notices an immobile, tender nodule. She should identify this finding as abnormal: True or False (a or b)? A. True B. False

correct answer is A. These findings are abnormal. Nodules indicate cancer; any pain or tenderness is usually caused by prostatitis; an inability to move the prostate indicates cancer; excessively hard fixed nodules indicate cancer; and swelling, is indicative of prostatitis.

A GRADUATE NURSE ASKS A MORE EXPERIENCED NURSE WHEN SHE SHOULD COMPLETE A NEURO ASSESSMENT DURING THE COURSE OF HER SHIFT. AN APPROPRIATE RESPONSE WOULD BE: A) You should not perform Neuro assessments while assessing other body systems. B) Neuro assessments can be performed covertly. C) You should only perform a Neuro assessment on admission. D) You should perform a Neuro assessment only when a patient complains of a headache.

correct answer is B. Neuro assessment can be conducted while you are performing other assessments of the body. You learn to be a spy (covert operator). For example, while the person is talking, you can note speech patterns, alertness, confusion, etc. when they respond appropriately (or not) to questions.

THE NURSE IS ASSESSING THE PATIENT'S VISUAL ACUITY USING THE SNELLEN CHART. THE PATIENT'S VISION IS 20/20. SHE NOTES THAT CRANIAL NERVE ___ IS INTACT. A) Cranial Nerve IV B) Cranial Nerve II C) Cranial Nerve VII D) None of the above

correct answer is B. Cranial Nerve II, the Optic Nerve is tested by assessing visual acuity using the Snellen chart, visual fields, and looking directly in the person's eyes with an ophthalmoscope.

THE NURSE IS PERFORMING A NEUROLOGICAL ASSESSMENT ON A 60 YEAR OLD PATIENT WHO SUFFERED A STROKE AND IS EXPERIEINCING LEFT-SIDED WEAKNESS. SHE ASKS THE PATIENT TO STICK HER TONGUE OUT AND MOVE IT FROM SIDE TO SIDE. THE NURSE NOTES THE PATIENT'S TONGUE DEVIATES TO THE LEFT SIDE AND SUSPECTS: A) Cranial Nerve IX damage B) Cranial Nerve XII damage C) Cranial Nerve VIII damage D) Cranial Nerve V damage

correct answer is B. Cranial Nerve XII: The Hypoglossal Nerve is assessed by having the person stick out their tongue and move the tongue from side to side noting smoothness of the movement. Any damage to the nerve would have the tongue deviating to the paralyzed side. Test tongue strength by having the person stick the tongue inside the cheek and they push against your hand. The tongue strength should be equal on both sides.

After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years.

correct answer is B. Early detection measures for colon cancer include a digital rectal examination performed annually after age 50 years, a fecal occult blood test annually after age 50 years, sigmoidoscopy every 5 years or colonoscopy every 10 years after age 50 years; and a PSA blood test annually for men over 50 years old

The nurse is describing how to perform a testicular self-examination to a patient. Which of these statements is most appropriate? A) "A good time to examine your testicles is just before you take a shower." B) "If you notice an enlarged testicle or a painless lump, call your health care provider." C) "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency." D) "Perform a testicular exam at least once a week to detect the early stages of testicular cancer."

correct answer is B. If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, he should call his health care provider for further evaluation. The testicle is egg-shaped and normally feels rubbery with a smooth surface. A good time to examine the testicles is during the shower or bath, when one's hands are warm and soapy, and the scrotum is warm. It should be performed once a month

A 60 year old patient expresses concerns about his sexual drive. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be attributed to: A) Decreased sperm production. B) Side effects of medications. C) Decreased sperm production. D) Decreased pleasure from sexual intercourse.

correct answer is B. Some older men withdraw from intimacy due to the loss of a spouse, depression, preoccupation with work, marital or family conflicts, side effect of medication such as antihypertensives, antidepressants, sedatives, narcotics, etc., heavy alcohol use, lack of privacy (living with adult children or in a nursing home), economic or emotional stress, poor nutrition or fatigue.

ALL OF THE FOLLOWING ARE COORDINATION AND SKILLED MOVEMENT ASSESSMENTS USED TO TEST CEREBELLAR FUNCTION EXCEPT: A) Finger-to-finger test B) Stereognosis C) Rapid alternating movements D) Finger-to-nose test

correct answer is B. Stereognosis is not used to assess cerebellar function. It is used to measure the discrimination ability of the sensory cortex. The images show the finger-to finger, patting the thighs and finger to nose tests.

A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the problem is: A) dysuria. B) stress incontinence. C) hematuria. D) urge incontinence

correct answer is B. Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing. Dysuria is pain or burning with urination. Hematuria is bleeding with urination. Urge incontinence is involuntary urine loss but it occurs due to an overactive detrusor muscle in the bladder that contracts and causes an urgent need to void.

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air from one side only when the nurse presses against the puffed cheeks. This would indicate dysfunction of which of these cranial nerves? A) Motor component of IV B) Motor component of VII C) Motor and sensory components of XI D) Motor component of X and sensory component of VII

correct answer is B. The findings listed reflect a dysfunction of the motor component of cranial nerve VII, the facial nerve.

A PATIENT REPORTS NUMBNESS ON THE LEFT SIDE OF HIS FACE. THE NURSE ASKS HIM TO CLOSE HIS EYES AND TOUCHES A COTTON BALL TO HIS FORHEAD, CHIN, AND BOTH CHEEKS TO ASESSS SENSORY FUNCTION OF WHAT CRANIAL NERVE? A) Cranial Nerve III B) Cranial Nerve IV C) Cranial Nerve V D) None of the above

correct answer is C. Cranial Nerve V, the Trigeminal Nerve has a sensory and motor function. The patient's facial sensation is assessed by touching a cotton ball to the person's forehead, cheeks and chin while their eyes are closed. The person would say "now" whenever they feel the touch on those areas.

The nurse is inspecting a 35 year old female patient's perianal area. Which of the following assessment findings would be considered abnormal? A) Smooth and even colored sacrococcygeal area B) Dark pink colored labia minora C) Excoriation, inflammation or swelling D) Moist, hairless anus

correct answer is C. A, B, & D are examples of expected findings when assessing the female genitalia.

WHICH STATEMENT IS TRUE ABOUT CRANIAL NERVE I, THE OLFACTORY NERVE? A. The Olfactory Nerve is not assessed. B) The Olfactory Nerve is tested by having the person say "light, tight, dynamite." C) The Olfactory Nerve is tested by having the person smell a familiar substance like coffee, lemon or vanilla. D) None of these statements are true.

correct answer is C. Cranial Nerve I, the Olfactory Nerve is tested by having the person smell a familiar substance like coffee, lemon or vanilla. Avoid using alcohol, vinegar or anything that is irritating to the nose as you risk stimulating the sensory branch of the trigeminal nerve (CN V).

A NURSE IS ASSESSING A PATIENT RECENTLY DIAGNOSED WITH PARKINSON'S DISEASE. SHE CORRECTLY NOTES WHAT ABNORMAL MOVEMENTS OF THE PATIENT'S BODY? A) Myoclonus B) Fasciculations C) Resting tremors D) Tics

correct answer is C. Resting tremors are coarse and slow. They disappear with sleep and partly or completely disappear with voluntary movement. They can be seen in someone with Parkinson's disease.

THE NURSE IS PERFORMING AN ORAL ASSESSMENT. SHE ASKS THE PATIENT TO STICK OUT HIS TONGUE AND SAY "AHH." SHE NOTES THAT HIS UVULA DEVIATES TO ONE SIDE. SHE SUSPECTS THERE MAY BE DAMAGE TO WHICH CRANIAL NERVE? A) Cranial Nerve IX B) Cranial Nerve XII C) Cranial Nerve X D) VII

correct answer is C. The motor function of the Vagus Nerve (CN X) is tested by having the patient say "aah" and noting the uvula rise to the midline. Any deviation to the side or absent movement indicates nerve damage. If it deviates to one side then you want to be careful when you give that person something to eat because they would be at risk for aspiration.

During an examination of an aging male, the nurse recognizes that normal changes to expect would be: A) loss of libido. B) increased pubic hair. C) decreased penis size. D) increased time for erection

correct answer is C. The older male is capable of sexual function as long as he is in reasonably good health, interested, and has a willing partner; the amount of pubic hair decreases, the penis size decreases; and because of the decreased testosterone levels, the sexual response time and intensity is lessened and an erection takes longer to develop, hence the reliance on medication and stimulants.

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? A) Glasgow Coma Scale B) Neurologic recheck examination C) Neurologic screening examination D) Complete neurologic examination

correct answer is D. The nurse should perform a Complete Neurologic Examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a person's level of consciousness. The Neurologic Recheck Examination is appropriate for persons with demonstrated neurologic deficits. The Screening Neurologic Examination is performed on seemingly well persons who have no significant subjective findings from the history.

THE NURSE IS USING THE DIAGNOSTIC POSITIONS TEST TO ASSESS HER PATIENT'S EXTRAOCULAR EYE MOVEMENT. SHE NOTES PARALLEL TRACKING OF BOTH EYES. SHE WOULD BE CORRECT IN DOCUMENTING NORMAL FINDINGS FOR WHICH CRANIAL NERVE (S)? A) Cranial Nerve VII B) Cranial Nerve I C) Cranial Nerve II D) Cranial Nerves III, IV & VI

correct answer is D. Cranial Nerves III (Oculomotor), IV (Trochlear) and VI (Abducens) can be assessed by leading the eyes through the six cardinal positions of gaze with the diagnostic positions test. A normal response is parallel tracking of the object with both eyes. This assesses movement of the extraocular muscles. You should note any muscle weakness during the assessment.

The nurse is examining an older female patient. Which of the following are normal changes that would be noted? A) The vagina is narrow and has lost its elasticity B) Labia & clitoris decrease in size C) Thinning pubic hair D) All the above

correct answer is D. All of these are age related changes seen with the female reproductive system

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? A) "It depends. Do you smoke?" B) "A Pap test needs to be performed annually until you are 65 years of age." C) "If you have two consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 3 years."

correct answer is D. Annual Pap smears are suggested until age 30. After age 30, the time frame can be safely extended to 3 years if the woman has had 3 consecutive normal Pap smears. However, annual screening is recommended if the woman's mother was prescribed and took the estrogen Diethylstilbestrol (DES) while pregnant with her as this has been found to pose great risk for certain types of vaginal cancers.

A woman has just been diagnosed with HPV or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for: A) Bladder Infection B) Uterine Prolapse C) Ovarian Cysts D) Cervical Cancer

correct answer is D. Cervical cancer is diagnosed by Pap tests and biopsy. It is almost always caused by persistent HPV infection. Risk factors are early age at first intercourse, multiple sex partners, cigarette smoking, and undetected HPV.

THE WIFE OF A 36 YEAR OLD PATIENT TELLS THE NURSE THAT SHE IS CONCERNED BECAUSE SHE NOTCIED HER HUSBAND HAS BEEN HAVING DIFFICULTY HEARING NORMAL CONVERSATION. THE NURSE SUSPECTS THE PATIENT MAY HAVE CRANIAL NERVE VIII DAMAGE. WHAT TESTS WOULD BE APPROPRIATE FOR THE NURSE TO USE TO CONFIRM HER SUSPICIONS OF DECREASED HEARING ACUITY? A) Whispered Voice Test B) Weber Test C) Rinne Test D) All the above

correct answer is D. Cranial Nerve VIII, the Acoustic (Vestibulocochlear) Nerve is tested by assessing the person's ability to hear some words, normal conversation, the Whispered Voice test, and using the tuning fork with the Weber test and the Rinne test.

THE NURSE IS ASSESSING THE PATIENT'S POSITION SENSE BY MOVING THE PATIENT'S FINGERS AND TOES IN THE UP, DOWN, AND NEUTRAL POSITION. THE PATIENT IS ABLE TO IDENTIFY WHICH POSITION THE NURSE IS MOVING THE LIMBS. THIS TEST IS CALLED: A) Graphesthesia B) Extinction C) Point location D) Kinesthesia

correct answer is D. Graphesthesia is the ability to "read" a number or letter by having it traced on the skin. Extinction is when you simultaneously touch both sides of the body at the same point and ask the person how many sensations they felt and where they felt the sensation. Point location is when you touch the skin, withdraw quickly and ask the person to point to the spot where they felt the touch.

A NURSE RECEIVING REPORT ON A PATIENT BEING ADMITTED WITH SYMPTOMS OF A STROKE ASKS WHEN THE PATIENT'S SYMPTOMS BEGAN. SHE KNOWS THIS INFORMATION IS IMPORTANT IN ORDER TO: A) Reduce long term brain damage B) Reduce disability C) Provide appropriate treatment D) All the above

correct answer is D. It is important to identify when the first signs of a stroke appeared. The time is important because of what is referred to as the Stroke window of opportunity (Time): Time lost is brain lost. Quick treatment may save the person's life and reduce disability. Receiving treatment within 3-4.5 hours can significantly reduce long-term brain damage.

Which of these statements about the testes is true? A) The lymphatics of the testes drain into the abdominal lymph nodes. B) The vas deferens is located along the inferior portion of each testis. C) The right testis is lower than the left because the right spermatic cord is longer. D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

correct answer is D. When it is cold, the cremaster muscle contracts, which raises the scrotal sac and brings the testes closer to the body to absorb heat necessary for sperm viability. The lymphatics of the testes drain into the inguinal lymph nodes. The vas deferens is located along the upper portion of each testis. The left testis is lower than the right because the left spermatic cord is longer.