N366 Exam 2 Prep U

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? Asking the client to flex his or her neck Compressing the arteries bilaterally Performing the examination while the client is seated Asking the client to swallow water

Compressing the arteries bilaterally

The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve? Abducens (VI) Accessory (XI) Hypoglossal (XII) Trochlear (IV)

accessory XI

Which action by the nurse is appropriate to provide a clear view of the uvula for observation? Depress the tongue slightly off center Ask the client to say "aaah" Press firmly on the back of the tongue Ask the client to stick out the tongue

ahhhhhh

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process? Air leaking from the alveoli into the pleural space Air being diverted from the trachea to the bronchi Air increasing in turbulence in a wide passage Air passing through constricted passageways

air passing through constricted passageways

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? Ask the client to remove the glasses before testing. Have the client keep the glasses on but occlude one eye. Test the client's near visual acuity instead. Use the E chart rather than the Snellen chart for testing.

ask the client to remove the glasses before testing

Which of the following would be best for a nurse to use when assessing for fremitus in a client? Dorsal hand surface Pads of fingers Ball of hand Fist

ball of hand

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? Inspection Auscultation Palpation Percussion

percussion

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? Hyperresonance Dullness Resonance Tympany

resonance

A client tells the nurse that it is difficult to hear normal conversation when in a room with a lot of noise. Which test should the nurse perform to assess the hearing ability of the client? Weber Rinne Otoscopic Romberg

weber

The nurse is conducting the health interview of an adult client who has sought care because of a "wicked cough" leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask? "Does your cough often cause you to be short of breath?" "Do you experience chest pain when you cough?" "How long have you been experiencing your cough?" "Are you now or have you ever been a smoker?"

"How long have you been experiencing your cough?" All of the listed questions are valid interview questions. However, gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections.

When visual acuity is tested using the Snellen eye chart, which result suggests better distance vision? 20/20 20/25 30/20 20/15

30/20

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? Client did not wear his glasses for this test and therefore it is not accurate. When 50 feet from the chart, the client can see better than a person standing at 20 feet. Client can read the 20/50 line correctly and two other letters on the line above. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern? Kussmaul's Cheyne-Stokes Eupnea Tachypnea

Cheyne-stokes

Which action by the nurse is consistent with Weber's test? The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear.

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

What characteristic nail color should the nurse recognize as an indication of hypoxia? Pink cyanotic Yellowish Greenish

cyanotic

Which of the following tests use a tuning fork between two positions to assess hearing? Whisper Watch tick Rinne Weber's

rinne

The nurse is assessing auditory acuity in a college student. Which test would the nurse perform to assess for loss of high-frequency sounds? Whisper test Rinne's test Weber's test Romberg's test

whisper test

During a health history, a 42-year-old male client reveals that he is seeing spots before his eyes. The nurse interprets this finding as the result of which of the following? Increased ocular pressure Vitamin A deficiency Normal findings for client's age Vascular spasm

normal findings for client's age

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location? On each side of the client's face, anterior and inferior to the ears On each side between the top of the ear and the eye Bilaterally, parallel to and anterior to the sternomastoid muscle Inferior to the lower jaw beneath the client's tongue

on each side between the top of the ear and the eye

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should position the client 609.6 cm (20 ft) away from the chart. ask the client to remove his glasses. ask the client to read each line with both eyes open. instruct the client to begin reading from the bottom of the chart.

position the client 609.6 cm (20 ft) away from the chart

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? Direct reflex Optic chiasm Consensual response Accommodation

consensual response

Which of the following would the nurse assess in a client with severe upper respiratory pneumonia? Pursed lip breathing Pain over the ribs Crepitus on palpation Increased warmth of the skin

crepitus on palpation

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following? Softly repeat the words "one-two-three." Say "ninety-nine." Cough each time the stethoscope is moved. Say the letter "e."

softly repeat the words "one-two-three"

The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by asking the client to take a deep breath and hold it. percussing upward from the base of the lungs. percussing downward until the tone changes to resonance. asking the client to exhale forcefully and hold his breath.

asking the client to exhale forcefully and hold his breath

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information? History of allergies History of dysphagia Frequency of nosebleeds Tonsillar enlargement

history of allergies

A client is diagnosed with bronchitis. Which of the following would the nurse hear on auscultation? Sibilant wheezes Fine crackles Sonorous wheezes Coarse crackles

sonorous wheezes Sonorous wheezes are often heard with bronchitis. Sibilant wheezes are often heard with acute asthma or chronic emphysema. Fine crackles, heard on late inspiration, suggest restrictive disease, such a pneumonia or heart failure. Coarse crackles may indicate pneumonia, pulmonary edema, or pulmonary fibrosis

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? Stridor Crackles Wheezes Rales

stridor

When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse? The lung is full of fluid The lung has an embolus The lung is overinflated The lung has become airless

the lung has become airless

A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor. Which of the following findings should the nurse expect on performing pectoriloquy? "Ninety-nine" is soft and muffled. Letter "E" is heard distinctly. "1-2-3" is heard clearly. Sound is louder and sounds like "A"

"1-2-3" is heard clearly. To perform whispered pectoriloquy, the nurse asks the client to whisper the phrase "one, two, three" while she auscultates the chest wall. Over areas of consolidation or compression, such as may occur with tumor, the sound is transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope. To perform egophony, the nurse asks the client to repeat the letter "E" while listening with the stethoscope. Over normal lung tissue, the sound will be soft and muffled but the letter should be distinguishable. In areas of consolidation, such as pneumonia, the letter "E" will sound louder and sound like the letter "A". Bronchophony uses the phrase "Ninety-nine."

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min

64 year old

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following? Diabetes mellitus Heart failure Chronic obstructive pulmonary disease System lupus erythematosus

COPD

Which action by the nurse indicates the appropriate use of ophthalmoscope? Hold the ophthalmoscope with the middle finger on the lens wheel Stand in front of the client with the light directly on the pupil Ask the client to gaze at an object straight ahead and slightly towards the floor Employ the right eye to examine the client's right eye Approach the client from the side using the same eye as being examined

Employ the right eye to examine the client's right eye

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? Document this as an expected assessment finding Refer the patient to the primary care provider promptly Perform a focused endocrine assessment Position the patient supine and reattempt palpation

Document this as an expected assessment finding

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? Refer the client for further medical evaluation Auscultate for egophony Perform bronchophony Have the client cough, then listen again

Have the client cough, then listen again

A nurse inspects the anterior thorax of a client with emphysema. Which change in the thorax should the nurse recognize as normal for this client? Horizontal position to the ribs with a costal angle of greater than 90 degrees Forward protrusion of the sternum causing the ribs to slope backwards Retraction of the intercostal spaces with an increase in respiratory effort Anterior posterior diameter is less than the transverse diameter

Horizontal position to the ribs with a costal angle of greater than 90 degrees Emphysema is a chronic air trapping condition in which the lungs hyperinflate. Over time this causes an increase in the anterioposterior diameter, resulting in a barrel chest configuration. This barrel chest results in a more horizontal position of the ribs and costal angle of more than 90 degrees. Forward protrusion of the sternum is called pectus carinatum which causes the ribs to slope backwards. Retraction of the intercostal spaces indicates increased respiratory effort and is not a normal finding. An anterior posterior diameter is less than the transverse diameter is a normal chest configuration.

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? Listen at each site for at least one complete respiratory cycle Move from anterior to posterior on the same side Instruct the client to breathe in and out rapidly through the mouth Use the diaphragm then the bell in each location

Listen at each site for at least one complete respiratory cycle

Which of the following would be most important for the nurse to remember when auscultating the thorax? Listen at each site for at least one complete respiratory cycle Have the client breathe deeply through the mouth Be alert to the client's comfort and offer rest periods Auscultate the base at the level of the sixth rib

Listen at each site for at least one complete respiratory cycle

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? Client's consensual pupil constricts in response to indirect light Eyes converge on an object as it is moved towards the nose Direct light shown into the client's pupils results in constriction The client and the examiner see the examiner's finger at the same time

The client and the examiner see the examiner's finger at the same time

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment? Cranial nerve V Cranial nerve VI Cranial nerve VII Cranial nerve VIII

VII

A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely? acute bacterial sinusitis allergic rhinitis rhinitis medicamentosa epistaxis

acute bacterial sinusitis

An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is 117 beats/min, respirations 36 breaths/min, blood pressure 110/64, and oxygen saturation 82%. What is the first nursing action? Administer oxygen Start an 18-gauge IV Leave the client and daughter so as not to overexcite them Call a code

administer oxygen

The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung is where? Anterior Posterior Laterally Medially

anterior

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? Applying pressure and assessing for induration Attempting to roll the structure up and down and side to side Palpating for lateral movement when the client swallows a sip of water Observing for hypertrophy when the client turns the head against resistance

attempting to roll the structure up and down and side to side

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform? Obtain a full set of vital signs. Percuss the client's thyroid. Auscultate the client's thyroid. Perform a swallowing assessment.

auscultate the client's thyroid

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what? Bradypnea Tachypnea Hyperventilation Hypoventilation

bradypnea

Which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia? Vesicular Bronchial Bronchovesicular Diminished

bronchial Bronchial sounds are normally heard over the main bronchi. The consolidation of the lung due to right lower lobe pneumonia may carry the bronchial sounds to the peripheral lung area. Vesicular sounds are heard from the bronchioles and lobes. Bronchovesicular lung sounds are normally heard over the main bronchi. Diminished breath sounds occur if the pneumonia has caused severe damage to the lung tissue.

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document this as which of the following? Vesicular breath sounds Bronchovesicular breath sounds Adventitious breath sounds Bronchial breath sounds

broncial breath sounds

The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client? "You have a high frequency hearing loss." "You have a conductive hearing loss." "You have nerve damage in your ears." "You have a unilateral hearing loss."

conductive hearing loss

When conducting the Weber test a client reports hearing the sound better in the right ear. What should this finding indicate to the nurse? Conductive hearing loss in the left ear Conductive hearing loss in the right ear Infection of the auditory canal of the left ear Ruptured tympanic membrane of the right ear

conductive hearing loss in the right ear

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding? Dyspnea Tachypnea Shortness of breath Anxiety

dyspnea

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following? Pneumonia Pectus excavatum Funnel chest Emphysema

emphysema

When percussing the scapula of a client, what would the nurse expect to hear? Resonance Dullness Flatness Hyperresonance

flatness

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative? Fluid in the alveoli Fluid in the bronchioles Fluid in the bronchus No fluid present

fluid in alveoli

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following? Fremitus Egophony Chest expansion Bronchophony

fremitus

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process? Paroxysmal nocturnal dyspnea Sleep apnea Heart failure Upper respiratory infection

heart failure Orthopnea, difficulty breathing when lying down, may be associated with heart failure. This may occur during sleep and wake the client up with severe shortness of breath. Paroxysmal nocturnal dyspnea is the term given to the severe dyspnea that wakes a person up from sleep. Sleep apnea may cause a person to feel fatigue during the day because of interrupted sleep but this syndrome is accompanied by cessation in breathing and heavy snoring and gasping sounds while sleeping. An upper respiratory infection may cause poor sleeping due to nasal congestion and cough but the client should not wake up feeling short of breath.

A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following? Hyperresonance Dullness Resonance Tympany

hyperresonance