Health Assessment Final Exam
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
A) parotid
The Glasgow Coma Scale (GCS) is used to measure all of the following functions EXCEPT: A) Limb ataxia B) Eye Opening C) Verbal Response D) Motor Response
A) Limb ataxia
The nurse is palpating the sinus areas. If the findings are normal, then the client should report which sensation? A) No sensation B) Firm pressure C) Pain during palpation D) Pain sensation behind eyes
B) Firm pressure
A 92-year-old client 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
C) Dysphagia
The nurse is performing an ear examination of an 80-year-old client. 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
A) A high-tone frequency loss
Match the following cranial nerves to the function or test used: Spinal Accessory Nerve (CN XI) The Optic Nerve (CN II) The Acoustic (Vestibulocochlear) Nerve (CN VIII) Cranial Nerves: III (Oculomotor), IV (Trochlear) and VI (Abducens) 1. Diagnostic Positions Test 2. Visual Acuity, visual fields 3. Whispered word test 4. Testing range of motion and strength on the neck, head, and shoulders
4, 2, 3, 1
The wife of a 65-year-old client 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
A) Frontal
The nurse is assessing a client 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.
A) It is the normal pathway for hearing.
When assessing the hypoglossal nerve (CN XII), the nurse looks at and tests: A) Movement and strength of the tongue B) The symmetry of facial structure C) Full, sustained eye opening D) The uvula rising to the midline when a person says "Ah."
A) Movement and strength of the tongue
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.
A) auricle.
During an assessment of a 20-year-old client 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.
A) dehydration.
During the history, a client 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.
A) vertigo.
The nurse is doing an assessment on a 21-year-old client and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the client? 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?"
A)"Are you aware of having any allergies?"
Which of the following would be considered subjective data? A. The client states that he has clear discharge coming out of his ears. B. You note that the client's ears are equal size and shape. C. The client is unable to hear the words on the Whispered Voice Test. D. The client's ear drum is a pearl gray color.
A. The client states that he has clear discharge coming out of his ears.
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 client has 22 total teeth D. The upper and lower jaw are not aligned
A. The teeth are white and the gums are coral pink
During a client 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
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) S.T.O.P. S-Stroke, T-Time to rest, O-Opt out, P-Poke to test B) F-Face Drooping, A-Arm weakness, S-Speech Difficulty, T-Time to call 911 C) F-Feel the face, A-Arm yourself, S-Stop, T-Time to rest D) F-Feet drooping, A-Arm Weakness, S-Speech difficulty, T-Time to stroke
B) F-Face Drooping, A-Arm weakness, S-Speech Difficulty, T-Time to call 911
The nurse is assessing a client who may have suffered a stroke. Which of these statements is true concerning areas of the brain? 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.
B) The hypothalamus controls temperature and regulates sleep.
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 client to repeat them. C) Ask the client to cover both ears simultaneously to occlude outside noise. D)Stand about 4 feet away to ensure that the client can really hear at this distance.
B) Whisper a set of random numbers and letters and ask the client to repeat them.
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.
B) filter out dust and bacteria.
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.
B) pearly gray and slightly concave.
The nurse is assessing an 80-year-old client. Which of these findings would be expected for this client? 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
C) A decreased ability to identify odors
A CLIENT 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
C) Cranial Nerves IX and X
The nurse is examining a client'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.
C) The purpose of cerumen is to protect and lubricate the ear.
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
C) Tonsils 3+/1-4+ with large white spots
A client has been shown to have 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 client what medications he is currently taking. D) look for the source of the obstruction in the external ear.
C) ask the client what medications he is currently taking.
A client with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the client 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.
C) conduct vibrations of sounds to the inner ear.
The nurse is assessing a client 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."
C)"This is a fungal infection caused by all the antibiotics you've received."
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
C. Frontal and Maxillary
The nurse is assessing the ear of an adult client. 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
C. Pull the pinna up and back and insert the scope
The nurse is assessing a patient's lungs by using the percussion technique. Which sound would the nurse expect to hear over healthy lung tissue? a. resonance b. dullness c. crackles d. wheezes
Correct Answer is A:Resonance
A clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is: a. Periodic breathing patterns b. Pursed lip breathing c. Unequal chest expansion d. hyperventilation
Correct Answer is B An individual with COPD may purse the lips in a whistling position. By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse.
Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position? a. Upper lobes-lateral chest b. Upper lobes-posterior chest c. Lower lobes-posterior chest d. Lower lobes-anterior chest
Correct Answer is C The posterior chest is almost all lower lobe
A palpable vibration increased with lobar pneumonia is also known as: A. Rhonchi B. Resonance C. Fremitus D. Crackles
Correct Answer is C: Fremitus Key term "palpable"
Which of the following terms is used to describe a decreased level of oxygen (O2) in the blood? a. anemia b. hypercapnia c. hypoxemia d. emphysema
Correct Answer is C: Hypoxemia
The nurse is auscultating a patient's lungs and hears discontinuous, high-pitched, short, popping sounds heard during inspiration, and not cleared by coughing. These are described as: a. bradypnea b. rhonchi c. crackles d. wheezing
Correct Answer is C: crackles
Upon receiving the patient's lab results, the nurse notes the patient has an increased level of carbon dioxide in the blood. Which of the following conditions would the patient be experiencing? a. resonance b. hypercapnia c. fremitus d. tachypnea
Correct Answer is b: hypercapnia
Your patient is exhibiting rapid shallow breathing, with a respiratory rate > 24 respirations per minute. Which of the following conditions are they experiencing? a. hypoxemia b. tachypnea c. fremitus d. resonance
Correct Answer is b: tachypnea
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.
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 client's eyes, the nurse notices a red glow in the 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 client'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.
The nurse is assessing the pupils of a client 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.
Stridor is a high pitched, inspiratory crowing sound commonly associated with: a. Upper airway obstruction b. Atelectasis c. Congestive heart failure d. Pneumothroax
Correct answer is A Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchial sounds c. Bronchophony d. Crackles
Correct answer is A wheezes Wheezes occur when air is squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions or tumors.
The nurse is assessing the client's trachea. Which of the following would be a normal finding? A. The trachea rising to midline when the client swallows B. The trachea deviating to the left when the client swallows C. The trachea deviating to the right when the client swallows D. The trachea not moving when the client swallows
Correct answer is A. The trachea should rise to the midline when the client swallows. If it deviates to one side or the other that can indicate stroke or tumor.
A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this client is most likely experiencing: A: Intermittent Claudication. B: Sore muscles. C: Muscle cramps. D: Venous insufficiency.
Correct answer is A: Intermittent Claudication The pain is brought on by activity and relieved with rest. Correct answer is A: Intermittent Claudication The pain is brought on by activity and relieved with rest.
Which of the following is an appropriate position to have the client assume when auscultating for extra heart sounds or murmurs? A: Roll toward the left side B: Roll toward the right side C: Trendelenburg position D: Prone position
Correct answer is A: Roll towards the left side Some murmurs disappear or are enhanced by a change in position. S3, S4 and mitral systolic murmurs may be heard only when on the left side Diastolic murmurs may only be heard when the person is leaning forward in the sitting position.
The nursea is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. a. Side-to-side b. Top-to-bottom c. Posterior-to-anterior d. Interspace-by-interspace
Correct answer is A: Side to side comparison
When assessing a client the nurse is unable to palpate the left dorsalis pedis pulse. What should the nurse do first? A) Document the finding B) Use the doppler to assess the pulse C) Call the physician and tell them the client has no pulse D) Start assessing the next client
Correct answer is B. The first thing that you should do is find a doppler and see if the pulse can be heard through ultrasound.
The nurse is preparing to perform a Modified Allen Test. Which is an appropriate reason for this test? A. To measure the rate of lymphatic drainage B. To evaluate the adequacy of capillary patency before venous blood draws C. To evaluate the adequacy of collateral circulation before cannulating the radial artery D. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
Correct answer is C A Modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a Modified Allen Test.
Which of the following chest configurations is an exaggerated posterior curvature of the thoracic spine that is associated with aging and physical fitness? a. Scoliosis b. Barrel chest c. Kyphosis d. Pectus Excavatum
Correct answer is C- Kyphosis An exaggerated posterior curvature of the thoracic spine that causes significant back pain and limited mobility. It is associated with aging, and people with adequate exercise habits are less likely to have kyphosis. Scoliosis is S shaped curvature of the spine Barrel chest is equal AP to transverse diameter and is associated with aging and chronic emphysema or asthma Pectus excavatum is a markedly sunken sternum and adjacent cartilages that is congenital.
A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness on percussion
Correct answer is C-Chest pain that is worse on deep inspiration and dyspnea. Undissolved materials originating in the legs or pelvis detach and travel through the venous system, returning blood to the right side of the heart and lodge to occlude the pulmonary vessels.
When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are A) mitral and tricuspid. B) tricuspid and aortic. C) aortic and pulmonic. D) mitral and pulmonic.
Correct answer is C. S2 heard best over the aortic & pulmonic valves (loudest at the base of the heart) Occurs with the closure of the semilunar valves (aortic & pulmonic valves) after the ventricles contract and signals the end of systole (dub)
A client'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 stethoscope.
When auscultating over a client's femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits: A: Are often associated with venous disease. B: Occur in the presence of lymphadenopathy. C: In the femoral arteries are caused by hypermetabolic states. D: Occur with turbulent blood flow, indicating partial occlusion. 28
Correct answer is D. Bruits occur with turbulent blood flow, indicating partial occlusion. A bruit is audible when the artery is occluded by ½ to 2/3, it's loudness increases as atherosclerosis worsens and disappears when the lumen is completely occluded.
The nurse is assessing the client's pupillary response to light. The nurse moves the penlight in from the side of the client'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
The nurse is performing an assessment on a client. Which of the following should the nurse ask to obtain subject data related to the client's gastrointestinal system? a. Have you experienced any changes in bowel habits? b. What medications are you taking? c. Do you have any headaches? d. Both a and b
Correct answer is d C would be used for a pain, head, face & neck, or neurological assessment
The nurse is teaching a client about health promotion of the gastrointestinal system. Which of the following statements would indicate a need for further teaching? a. "I should try to drink at least 8 glasses of water daily." b. "I should try to avoid having high fatty foods in my diet." c. "I plan to exercise more so I can maintain a healthy weight." d. "The amount of alcohol I have should not affect my health if I dilute it with water."
Correct answer is d The liver helps the body to get rid of waste products and plays a vital role in fighting infections, particularly in the bowel. Drinking alcohol can increase one's risk of developing liver disease and cause irreparable damage to the liver which is why it is important to promote gastrointestinal health by avoiding excessive alcohol intake.
How should the nurse document mild, slight pitting edema on the ankles of a heart failure client? A. 1+ B. 2+ C. 3+ D. 4+
Correct answer: A 1+ 1+ Mild pitting, slight indentation, no perceptible swelling of the leg 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains for a short time, leg looks swollen 4+ Very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted
In assessing the carotid arteries of an older client with cardiovascular disease, the nurse would: A) palpate the artery in the upper one third of the neck. B)listen with the bell of the stethoscope to assess for bruits. C) palpate both arteries simultaneously to compare amplitude. D) instruct client to take slow deep breaths during auscultation. 26
Correct answer: B If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain.
Which of the following subjective data would the nurse want to collect for the client when performing a Head, Face and Neck Exam? (Select all that apply) A. If 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
The nurse is educating the client about risk factors for cardiovascular disease. Which of the following risk factors for cardiovascular disease are modifiable? Select all that apply. A: Abnormal lipids B: Smoking C: Gender D: Hypertension E: Diabetes F: Family history
Correct answers are A: Abnormal lipids, B: Smoking, D: Hypertension & E: Diabetes
Which of the following are functions of the respiratory system? (Select all that apply) a. Supplying oxygen to the body for energy production b. Removing carbon dioxide as a waste product c. Wound repair d. Maintaining acid-base balance e. Maintenance of heat exchange f. Identification
Correct answers are a, b, d and e Answers c and f are functions of the skin The four major functions of the respiratory system include: Supplying oxygen to the body for energy production Removing carbon dioxide as a waste product of energy reactions Maintaining homeostasis (acid-base balance) of arterial blood Maintaining heat exchange
The nurse is asking the client for subjective data before performing a cardiac and great vessel assessment. Which of the following should the nurse ask? Select all that apply A) Do you ever have any dyspnea? B) Have you noticed any edema? C) Do you have any history of respiratory infections? D)Have you noticed any skin pigmentation changes? E) Have you had any chest pain?
Correct answers: A, B, E Answer C would be for a respiratory assessment and answer D would be for skin assessment.
A nurse is performing an abdominal assessment. The nurse correctly observes the following assessment findings when inspecting a client's abdomen. Select all that apply. A. Contour and symmetry B. Appearance of umbilicus C. Skin color D. Demeanor
Correct answers: a, b, c & d During inspection you should observe: Contour (Flat, rounded, concave, and distended) Symmetry (Any bulges or masses?) Appearance of umbilicus (Midline, inverted, can be everted with pregnancy) Skin (Should be smooth and even, note any striae) Pulsation or movement Hair Distribution (Hair pattern) Demeanor (Comfortable, relaxed)
The nurse is taking the history of a client 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?"
D) "Was there any relationship between the ear pain and the discharge you mentioned?"
A female client is in the clinic with weakness in her left arm and leg that she has noticed for the past week. which type of neurologic examination would be most appropriate for this client? A) Glasgow Coma Scale B) Neurologic Recheck Examination C) Neurologic Screening Examination D) Complete Neurologic Examination
D) Complete Neurologic Examination
The nurse is assessing a client who has a hearing impairment. How should the nurse communicate with this client? 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 client and speak slowly.
D) Face the client and speak slowly.
A nurse is caring for a client whose daughter reports having "behavioral" problems. The nurse knows that the client's change in personality, behavior, emotions, and intellectual function is related to which area of the brain? A) Broca's area B) The temporal lobe C) Wernicke's area D) The Frontal Lobe
D) The Frontal Lobe
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 client: A) demonstrates ability to hear normal conversation. B) sticks tongue out midline without tremors or deviation. C) follows an object with both eyes without nystagmus or strabismus. D) moves the head and shoulders against resistance with equal strength.
D) moves the head and shoulders against resistance with equal strength.
Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X (Vagus)? A)Observe the client's ability to articulate specific words. B)Observe the client's ability to move the shoulders against resistance. C)Have the client stick out the tongue and observe for tremors or pulling to one side. D)Ask the client to say "ahhh" and watch for movement of the soft palate and uvula.
D)Ask the client to say "ahhh" and watch for movement of the soft palate and uvula.
The nurse is assessing a client's neck ROM. The nurse would correctly expect the client to be able to perform which movements with the neck? A. Flexion, hyperextension, rotation and lateral bending B. Rotation, supination, inversion, flexion C. Lateral bending, abduction, adduction, forward flexion D. Eversion, pronation, external rotation, hyperextension
The correct answer is A. A client with normal neck ROM should be able to perform flexion, hyperextension, rotation and lateral bending.
The nurse is palpating a client's 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.
Which statement is true regarding the arterial system? A: Arteries are large-diameter vessels. B: The arterial system is a high-pressure system. C: The walls of arteries are thinner than those of the veins. D: Arteries carry deoxygenated blood back to the heart
The correct answer is B. The arterial system is a high pressure system. The heart pumps freshly oxygenated blood through the arteries to the body tissues. The pumping heart makes this a high pressure system.
Freshly oxygenated blood enters the heart through the ___, and is pumped out to the body through the ____. A) Right atrium; aorta B) Left atrium; aorta C) Right ventricle; pulmonary arteries D) Left ventricle; pulmonary arteries
The correct answer is B; Freshly oxygenated blood enters the heart through the left atrium, and is pumped out to the body through the aorta.
The nurse is charting on a client'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 Accommodation C. Pupils Equal, Round, React to Light and Accommodation D. Pupils Even, Rigid, Restrict from Light, and Accommodation
The correct answer is C Pupils Equal, Round, React to Light, and Accommodation
The nurse is teaching the client about health promotion of the cardiovascular system. Which of the following statements would indicate a need for further teaching? A) " I would like some information about ways to help me quit smoking." B) "I should try to cut down on the amount of saturated fat I eat in my diet." C) "Even though my dad had a heart attack, I don't need to get screened for heart issues earlier than anyone else." D) " I should try to start an aerobic exercise program."
The correct answer is C. If the client has a family history of cardiovascular disease, they should receive early screening
The nurse is educating a 55-year-old client on breast self-examination (BSE.) Which of these statements by the client indicates understanding of the information provided? "The best time for postmenopausal women to perform BSEs is____________" A. "On the same day every month." B. "Daily, when I shower or bathe." C. "One week after my menstrual period." D. "Annually with my annual gynecologic examination."
The correct answer is a Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform BSEs on a monthly basis. The pregnant or menopausal woman who is not having menstrual periods should be advised to select a familiar date to examine her breasts each month—for example, her birth date or the day the rent is due. Choosing the same day of the month is a helpful reminder to perform the examination.
During an annual physical examination, a 43-year-old client states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: A: BSEs may detect lumps that appear between mammograms. B: BSEs are unnecessary until the age of 50 years. C: She is correct—mammography is a good replacement for BSE. D: She does not need to perform BSEs as long as a physician checks her breasts annually.
The correct answer is a The monthly practice of breast self-examination (BSE), along with clinical breast examination (CBE) and mammograms, are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms hence the importance of the BSE.
The function of the trachea and bronchi is to: a. Transport gases between the environment and the lung parenchyma b. Condense inspired air for better gas exchange c. Moisturize air for optimum respiration d.Increase air turbulence and velocity for maximum gas transport
The correct answer is a The trachea and bronchi transport gases between the environment and the lung parenchyma
During an assessment, the nurse notices that the client's umbilicus is enlarged and everted. The nurse recognizes this as: A: Abnormal: May be an umbilical hernia B: A normal result of aging C: Likely caused by constipation D: A rare occurrence
The correct answer is a The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect
The nurse is assessing a client's abdomen. She places the diaphragm of the stethoscope in the area where bowel sounds are prominent which is: A: The RLQ of the abdomen B: The RUQ of the abdomen C: The LUQ of the abdomen D: The LLQ of the abdomen
The correct answer is a To effectively assess for bowel sounds start at the right lower quadrant (RLQ) which is the location of the ileocecal valve. That is where the most active part of bowel sounds will be as it is where our GI tracts are most active.
The nurse is assessing a client's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation by displaying the breast against the chest wall? A. Supine with the arms raised over her head B. Sitting with the arms relaxed at her sides C. Supine with the arms relaxed at her sides D. Sitting with the arms flexed and fingertips touching her shoulders
The correct answer is a The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm(s) over her head. This position helps to flatten the breast tissue and displace it medially across the chest wall for better viewing and palpating of any abnormalities. Any significant lumps will then feel more distinct.
During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. The nurse understands that before reporting this finding as "absent bowel sounds" it is important to listen for at least _____ in each quadrant. A.1 minute. B. 5 minutes. C.10 minutes. D. 2 minutes
The correct answer is b Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent. If unsure, ask for help from a more experienced nurse.
During a breast health assessment, the client states that she has noticed pain in her left breast. An appropriate response to this by the nurse would be: A: "Don't worry about the pain; breast cancer is not painful." B: "I would like some more information about the pain in your left breast." C: "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." D: "Breast pain is almost always the result of benign breast disease."
The correct answer is b Breast pain occurs with trauma, inflammation, infection, or benign breast disease. The nurse will need to gather more information about the client's pain rather than make statements that ignore the client's concerns.
The nurse is performing percussion by tapping on a client's abdomen in the left upper quadrant (spleen) and right upper quadrant (liver). Which of the following would be an expected assessment finding in these two areas of the GI system? A: Resonance B: Dullness C: Tympany D: Hyperresonance
The correct answer is b Percussion notes normally heard during the abdominal assessment include tympany over the stomach and intestines, because air in the intestines rises to the surface when the person is supine, and dullness over solid organs such as the liver and spleen.
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: A: The largest quadrant of the breast. B: The location of most breast tumors. C: Where most of the suspensory ligaments attach. D: More prone to injury and calcifications than other locations in the breast.
The correct answer is b Research on the incidence of breast cancer has revealed that cancerous breast tumors tend to appear in the upper outer quadrant (Tail of Spence) of either breast. However a breast mass in any quadrant has the potential to be cancerous.
A client comes to the clinic with what he calls a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. Which of the following statements is true about breast cancer? A. Breast masses in men are difficult to detect because of minimal breast tissue. B. Gynecomastia is a benign growth of the breast tissue. C. Breast cancer is more likely to occur in men than women. D. Gynecomastia is an enlarged cancerous nodule located in the breast tissue.
The correct answer is b The early spreading to axillary lymph nodes is attributable to minimal breast tissue. One percent of all breast cancers occurs in men; less likely than with women. Gynecomastia is a benign growth of the breast tissue which occurs in about one half of adolescent boys at age 13 or 14. It is non-cancerous.
The nurse is preparing to examine a client who reports right lower abdominal pain. The nurse's priority would be to: A. Palpate the tender area first. B. Palpate the tender area last. C. Avoid palpating the tender area. D. Notify the physician.
The correct answer is b The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. It is important to perform an examination of the client before notifying the physician.
A nurse is performing an assessment on a client. Which of the following statements demonstrates her understanding of the rationale for correct sequencing for an abdominal assessment? A. "It is important to sequence the exam to prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation." B. "It is important to sequence the exam to determine areas of tenderness before using percussion and palpation." C. "It is important to sequence the exam to avoid distorting the client's bowel sounds." D. "It is important to sequence the exam to allow the client more time to relax and be more comfortable with the physical examination."
The correct answer is c Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
The nurse is palpating a client's breasts during a seated examination. She notes the client has large pendulous breasts. What is the most appropriate course of action for the nurse to take? A: Have a physician perform the assessment B: Have another nurse continue the assessment C: Use the bimanual technique to perform the assessment D: Refer the client for a breast scan
The correct answer is c The bimanual technique is: Used for large pendulous breasts Performed with the client seated A technique where the examiner palpates breast tissue against the supporting hand
During an examination of a client, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? A. Breasts should always be symmetric. B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. C. Asymmetry is not unusual, but the nurse should verify that this change is not new. D. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.
The correct answer is c The nurse should assess for symmetry in size and shape. It is common to have slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth.
During the physical examination, the nurse notices that the client has an inverted left nipple. Which statement regarding this is most accurate? A. Normal nipple inversion is usually bilateral. B. Unilateral inversion of a nipple is always a serious sign. C. The nurse should determine whether the inversion is a recent change. D. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
The correct answer is c The nurse should distinguish between a recently retracted (inverted) nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out; that is, if it is not fixed. Recent nipple retraction signifies acquired disease.
The nurse is educating a client on breast self-examination (BSE). Which of these statements by the client indicates understanding of the proper BSE technique? A. "The best time to perform the BSE is in the middle of my menstrual cycle." B. "A woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue." C. "The best time to perform the BSE is 4 to 7 days after the first day of my menstrual cycle." D. "I do not need to perform a BSE until after my baby is born."
The correct answer is c The nurse should help each woman establish a regular schedule of self-care. The best time to conduct a BSE is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested.
A nurse is performing an assessment on a client who reports abdominal pain. Which of the following actions should the nurse implement to promote relaxation of the client's abdomen during the assessment? A. Position the client supine, with the knees bent. B. Examine the painful areas first. C. Distract the client. D. Both a and c
The correct answer is d Bending the knees promotes abdominal muscle relaxation You can distract the client by holding a conversation while performing the assessment Painful areas should be examined last to avoid muscle guarding
The nurse is aware that one change that may occur in the gastrointestinal system of an aging client is: A: Increased salivation. B: Increased liver size. C: Increased esophageal emptying. D: Decreased gastric acid secretion.
The correct answer is d Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases.
The nurse is teaching a client about risk factors for breast cancer. She correctly includes which of the following risk factors? A: Breastfeeding an infant for more than 6 months. B: A low cholesterol diet. C: Physical activity. D: Menstruation before age 12 or menopause after age 55.
The correct answer is d Risk factors for breast cancer include: No history of breast feeding A high-fat diet Physical inactivity Refer to Table 17- 2 for other risk factors
The nurse is caring for a client who reports having abdominal pain. After inspecting the client's abdomen, the nurse would be correct in performing what assessment technique? A. Deep palpation B. Percussion C. Light Palpation D. Auscultation
The correct answer is d You must perform the least invasive things first. If the person is having abdominal pain, deep palpation will most likely hurt.
A nurse is performing a client assessment. Which of these clinical situations, if noted, should the nurse consider to be outside normal limits? A. The client has had one pregnancy. Her breast examination reveals breasts that are soft and slightly sagging. B. The client has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. C. The client has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is somewhat engorged. She states that the examination was slightly painful. D. The client has had two pregnancies. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
The correct answer is d Except in pregnancy and lactation, any discharge is abnormal. In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is especially noticeable in large breasts. If any discharge appears, the nurse should note its color, odor, and consistency.
