Assessments Chapter 27 and 28

Crainal Nerve IV

to trochlear m

Cranial Nerve V

touch trigeminal b

Cranial Nerve X

velvet (vestibular/auditory) b

Cranial Nerve VIII

very vagus s

The nurse teaches a student nurse how to document findings after a genital assessment. Which documentation by the student nurse indicates effective learning? "No hernias" "The patient has no hernias." "No inguinal, femoral, umbilical hernias" "No mass found on palpation of the inguinal area"

"No hernias" Proper documentation of patient data is important, because it helps in diagnosing and decision making during treatment. The nurse should use short and simple phrases such as "no hernia" for documentation, because it saves time while still providing accurate data. Introductory phrases and redundant descriptions should be avoided, because these may create confusion and consume extra time to read and write. Therefore, the nurse should not use introductory phrases like "the patient." The documentation "No inguinal, femoral, umbilical hernias" includes redundant phrases, so this is not an ideal documentation note. The statement "No mass found on palpation of the inguinal area" does not provide clear information of what is being assessed in the patient. Therefore, this kind of documentation is also incorrect.

Which reflexes would the nurse test by using a reflex hammer? Red reflex Moro reflex Achilles reflex Patellar reflex Plantar reflex

Achilles reflex Patellar reflex Plantar reflex A reflex hammer is a medical instrument that helps to test deep tendon reflexes in the patient. The Achilles reflex can be observed when the Achilles tendon, situated at the ankle, is tapped with the blunt end of a reflex hammer. The patellar reflex can be observed by tapping the deep tendons situated in the knee. The plantar reflex can be observed when the sole of the foot is stroked with a reflex hammer. The red reflex can be observed by focusing the light produced by an ophthalmoscope. The Moro reflex can be triggered by producing loud sounds. Therefore, the nurse would not use a reflex hammer to check for the red reflex or the Moro reflex.

While performing a genital examination of a female patient, the nurse concludes that a patient has normal genitalia. Which observation by the nurse supports this conclusion? Presence of negative Romberg sign in the patient Absence of pink vaginal wall and cervix in the patient Presence of small amount of malodorous cervical discharge Absence of acetowhitening on swabbing of the vaginal mucosa with acetic acid

Absence of acetowhitening on swabbing of the vaginal mucosa with acetic acid The nurse performs the genital examination in a female patient by swabbing the mucosa with acetic acid. The absence of acetowhitening due to blanching of the skin indicates that the patient has normal genitalia. The presence of even a small amount of malodorous cervical discharge indicates that the patient may have infection. Romberg sign is used to assess balance in the patient. The normal vaginal wall and cervix are pink in color; therefore, the absence of a pink-colored vaginal wall and cervix does not indicate normal genitalia in the patient.

While assessing an infant, the nurse pulls the infant's arm across its chest and finds that the infant's elbow does not cross the midline. What should the nurse infer from this finding? Absence of the scarf sign Presence of the Moro reflex Absence of the Ortolani sign Presence of the Babinski reflex

Absence of the scarf sign The scarf sign helps to determine muscle tone. If an infant's elbow does not cross its midline, which it should not, then it indicates that the infant lacks the scarf sign. If the infant does not cry or does not demonstrate a startle response when hearing a loud noise, then it indicates there is no Moro reflex. The Ortolani test helps to determine if the infant has a hip dislocation. Absence of a clunk on flexing the hips and knees indicates absence of the Ortolani sign in the infant. If the infant does not raise the foot and fan the toes after receiving a gentle stroke on the foot, it indicates that the infant lacks a Babinski reflex.

The nurse, while checking the vital signs, finds that the patient's blood pressure is decreased in the lower extremities. Which test does the nurse perform to evaluate the patient's condition? Romberg test Gag reflex test Babinski reflex test Ankle brachial index test

Ankle brachial index test

What intervention does the nurse perform to test the stereognosis of a patient? Ask the patient to perform the rapid alternating movements test. Ask the patient to run each heel down the shin of the opposite leg. Ask the patient to extend the arms fully and touch the nose with a finger. Ask the patient to identify an object placed in the hand without visual clues.

Ask the patient to identify an object placed in the hand without visual clues. The nurse places a familiar object such as a key into the patient's hand and asks the patient to identify the object without looking. This enables the nurse to test the stereognosis of the patient. The nurse tests the cerebellar function of the upper extremities by asking the patient to perform the rapid alternating movements test. The patient is asked to run each heel down the shin of the opposite leg to test the cerebellar function of the lower extremities. The finger-to-nose test is performed by extending the arms fully and touching the nose with a finger. This test helps test the cerebellar function of the upper extremities.

What does the nurse examine during bimanual examination? Cervix Uterus Adnexa Femoral pulse Patellar reflex

Cervix Uterus Adnexa Bimanual examination is done using both hands. It is performed during pelvic or vaginal examination. The nurse assesses the patient's cervix, uterus, and adnexa using the bimanual examination. Palpation of the femoral pulse does not require both hands. Patellar reflex is a deep tendon reflex that is assessed by percussing the patellar tendon using a reflex hammer. Femoral pulse and patellar reflex are not associated with bimanual examination.

Which areas does the nurse assess by using a penlight during an adolescent's physical examination? Buccal mucosa Palpebral slant Nares and septum Corneal light reflex Tympanic membranes

Buccal mucosa Nares and septum Corneal light reflex The buccal mucosa is examined with a penlight during an examination of the mouth. The nurse examines the nares and nasal septum by using a penlight while assessing the adolescent's nose. The nurse also assesses the corneal light reflex by using a penlight during the eye examination. The palpebral slant is assessed by inspection during the examination of the eye. The nurse uses an otoscope to inspect the tympanic membranes while examining the adolescent's ears.

What is the most likely reason for assessing a young child's ear? Assessing for startle reflex Checking for a foreign body Assessing for extra skin tags Inspecting alignment of auricles

Checking for a foreign body The nurse is most likely to assess a young child's ear to examine for the presence of a foreign body. A neonate or a young infant may be assessed for a startle reflex in response to a loud noise, but a young child would not be assessed for this. A neonate is also assessed for extra skin tags or pits and alignment of the auricles during an ear examination.

What does the nurse assess while examining the posterior and lateral side of the chest? Shoulder shrug Tactile fremitus Epitrochlear nodes Costovertebral angle Length of the spinous process

Costovertebral angle Length of the spinous process Tactile fremitus Tactile fremitus refers to the vibration that is felt in the chest when a patient speaks. It helps in assessing the condition of the lungs. The nurse assesses tactile fremitus while assessing the posterior side of the chest, because voice vibrations are also felt on the posterior side. The acute angle at the twelfth rib and vertebral column is referred to as the costovertebral angle. It is measured while assessing the posterior chest and is helpful in determining the presence of lung pathology. The length of the spinous process, which is present in the posterior sides of the chest, is assessed while examining the spine. The nurse assesses the shoulder shrug while examining the neck movements. Epitrochlear nodes are present in the arms, so the nurse assesses the epitrochlear nodes while assessing the upper extremities.

What intervention should the nurse incorporate in order to assess a child's eye during a cover test? Cover the eye with an index card or thumb. Direct a moving penlight in front of the eye. Inspect the fundus with an ophthalmoscope. Elicit the blink reflex with the help of a penlight.

Cover the eye with an index card or thumb. The nurse assesses a young child's eye by covering it with an index card or thumb while performing the cover test. A moving penlight is directed in front of the eye to assess the cardinal positions of gaze. An ophthalmoscope is not used to assess the eye during the cover test. It is used to elicit the red reflex and inspect the fundus. The cover test does not include assessment of the blink reflex with the help of a penlight.

While testing the extraocular muscles, the nurse notes that the patient has improper eye movements. Which cranial nerve damage does the nurse suspect in the patient? Cranial nerve III Cranial nerve IV Cranial nerve VI Cranial nerve VII Cranial nerve IX Eugene off target

Cranial nerve III Cranial nerve IV Cranial nerve VI There are six extraocular muscles that control the eye movements. These muscles are innervated by three cranial nerves, III, IV, and VI. Therefore, damage to these cranial nerves results in improper eye movement in the patient. Cranial nerve VII innervates the facial muscles; therefore, damage to this nerve results in facial asymmetry. Cranial nerve IX innervates the tongue and is responsible for the perception of the taste sensation.

While examining a patient, the nurse finds that the patient has an impaired gag reflex. Which nerves does the nurse expect to be responsible for this condition? Cranial nerve III Cranial nerve VII Cranial nerve IX Cranial nerve X Cranial nerve XII

Cranial nerve IX Cranial nerve X Lesions of cranial nerve IX (or the glossopharyngeal nerve) and cranial nerve X (or the vagus nerve) cause an impaired gag reflex, which in turn causes difficulty in swallowing. Therefore, the nurse expects that the patient has a lesion in cranial nerves IX or X. Cranial nerves III, XII, and VII are not associated with the gag reflex. Cranial nerve III is associated with eye movements; damage to this nerve may result in extraocular muscle dysfunction. Cranial nerve XII is associated with the movements of the tongue. Cranial nerve VII is associated with the symmetry of face and the depiction of facial expressions.

While assessing pain perception in a patient, the nurse finds that the patient has a distorted facial expression toward a pain stimulus. Which cranial nerve damage does the nurse screen for in the patient? Cranial nerve IV Cranial nerve VI Cranial nerve VII Cranial nerve IX

Cranial nerve VII Facial muscles control the facial expressions. Cranial nerve VII (or the facial nerve) innervates the facial muscles; therefore, damage to cranial nerve VII would result in a distorted facial expression in the patient. Cranial nerves IV, VI, and IX do not innervate the facial muscles; hence, any damage to these nerves would not result in distorted facial expressions. Cranial nerves IV and VI innervate the extraocular muscles, whereas cranial nerve IX innervates the tongue.

While completing a neuromuscular assessment in a newborn, the nurse turns the newborn's head from one side to the other. Which reflex can the nurse test in the newborn with this intervention? Grasp reflex Rooting reflex Babinski reflex Doll's eye reflex

Doll's eye reflex The doll's eye reflex helps to determine neuromuscular functioning in a newborn. While testing the doll's eye reflex, the nurse turns the newborn's head from one side to the other and observes the eye movements. To test the Babinski reflex in the newborn, the nurse gently strokes the outer side of the sole of the newborn's foot. The rooting reflex is tested by the nurse gently stroking the newborn's cheeks with a finger and observing whether the newborn turns its head and sucks the finger. The grasp reflex is tested when the nurse places an object in the newborn's palm and determines the newborn's ability to grasp and curl the fingers.

bimanual examination

Examination done using both hands

Which part of the body should the nurse examine to assess cranial nerve VII? Eye Face Mouth Throat

Face The nurse examines the face of the patient to assess cranial nerve VII. The facial expression and symmetry of the face indicate normal functioning of cranial nerve VII. The nurse examines the eyes to test the visual fields and assess the functioning of cranial nerve II. The patient is asked to stick out the tongue during an examination of the mouth to assess cranial nerve XII. The nurse examines the throat to assess the mobility of the uvula and the gag reflex to assess cranial nerves IX and X.

What does the nurse palpate while assessing the inguinal area of a patient? Radial pulse Femoral pulse Dorsalis pedis Popliteal pulse

Femoral pulse The large artery present in the inguinal area is known as the femoral artery, which is present near the inguinal folds and supplies blood to the lower limbs. Therefore, the nurse palpates the femoral artery while examining the inguinal area. The radial artery is present at the wrist, so the nurse palpates radial pulse while examining the upper extremities. The dorsalis pedis is the artery present in the lower limb, which carries blood to the dorsal surface of the foot. Therefore, the nurse palpates the dorsalis pedis while examining the lower limb. Popliteal pulse is present above the knee. The nurse palpates the popliteal pulse while examining the lower limbs.

Which tests does the nurse perform while assessing the cerebellar function of a patient? Occult blood test Confrontation test Finger-to-nose test Whispered voice test Rapid-alternating-movements test

Finger-to-nose test Rapid-alternating-movements test The nurse performs the finger-to-nose test and the rapid alternating movements test to assess the cerebellar function in the patient. In the finger-to-nose test, the nurse asks the patient to extend the arm fully and then touch the nose. In the rapid alternating movements test, the nurse asks the patient to place one hand over the other and then flip one hand back and forth as fast as possible. The nurse performs the occult blood test to determine the abnormalities associated with the gastrointestinal system in the patient. The nurse performs the confrontation test to evaluate the visual fields in the patient. The whispered voice test is conducted to determine a hearing defect in the patient. p. 781

Which assessment should the nurse include in order to assess an infant's upper extremities? Grasp reflex Rooting reflex Babinski reflex Stepping reflex

Grasp reflex The grasp reflex is used to assess an infant's upper extremities. The nurse places a finger in the infant's palm to note the grasp reflex. The nurse checks the rooting reflex while assessing an infant's mouth and throat. The Babinski reflex is the fanning of the toes when the outside of the sole of the foot is stroked. This reflex is noted during assessment of the lower extremities. The stepping reflex is elicited during the neuromuscular assessment of the infant.

The nurse is evaluating the neuromuscular development in a newborn. Which intervention would the nurse follow in order to test the stepping reflex in the newborn? Gently place a rattle in the palms of the newborn. Lay the newborn down and turn the head to one side. Give a gentle stroke on the newborn's cheek with a finger. Hold the newborn upright and let a foot touch the table.

Hold the newborn upright and let a foot touch the table. The stepping reflex is triggered by touching the newborn's feet on a hard surface. This helps the nurse evaluate whether the newborn has proper neuromuscular development. Therefore, in order to test the stepping reflex, the nurse would hold the newborn in an upright position to allow a foot to touch the table. The nurse would place a rattle in the newborn's palm in order to assess the palmar, or grasp, reflex. The nurse would place the newborn in a supine position and turn the head to one side while testing the tonic neck reflex. When testing the rooting reflex in the newborn, the nurse would give a gentle stroke on the newborn's cheek.

Cranial Nerve VI

and abducnes m

Cranial Nerve VII

feel facial b

What interventions does the nurse perform during the examination of a male patient's rectum? Inspect the perianal area. Check for inguinal hernia. Obtain a stool specimen. Palpate the prostate gland. Teach testicular self-examination.

Inspect the perianal area. Obtain a stool specimen. Palpate the prostate gland. While examining the male patient's rectum, the nurse inspects the perianal area for lesions. The nurse palpates the prostate gland to assess for abnormalities. A stool specimen is obtained to test for the presence of occult blood. While examining the male genitalia, the nurse assesses the patient for inguinal hernia and teaches testicular self-examination.

Which intervention does the nurse perform while assessing the breasts in a patient? Percuss the costovertebral angle Palpate the epitrochlear nodes Stand closely and check for Romberg sign Inspect the supraclavicular and infraclavicular areas

Inspect the supraclavicular and infraclavicular areas During the assessment of the breast, the supraclavicular and the infraclavicular areas are well exposed and can be easily assessed. The costovertebral angle is assessed while examining the posterior chest wall. Epitrochlear nodes are present in the arms and are assessed during the examination of the upper extremity. Therefore, the nurse will not palpate the epitrochlear nodes. While performing breast examination, the nurse does not check for Romberg sign. The Romberg test is used to assess the balance, vestibular function, and vision of the patient.

Which organ would the nurse be able to feel when doing deep palpation of the abdomen? Liver Spleen Kidney Bladder

Kidney The kidney are located deep inside the abdomen, so the nurse would deeply palpate the patient's abdomen. The liver, spleen, and bladder require only light palpation for assessment.

The nurse places an infant on a soft, padded surface while gently lifting the infant by supporting the head. After a while, the nurse allows the infant's head and trunk drop back a short way. What reflex is the nurse observing by doing this? Red reflex Moro reflex Babinski reflex Doll's eye reflex

Moro reflex The Moro reflex determines neurologic development. Therefore, in order to determine the presence of the Moro reflex in a newborn, the nurse would allow the infant to fall back. During this test, the nurse would support the newborn by holding its arms in order to prevent injury. In order to test the red reflex in the newborn, the nurse would use an ophthalmoscope. The nurse would give a gentle stroke on the outer side of the newborn's sole in order to assess the Babinski reflex. In order to evaluate the doll's eye reflex, the nurse would turn the newborn's head to either side and observe its eye movements.

Which assessment includes size, shape, and strength parameters? Breast examination Abdominal examination Cardiovascular examination Musculoskeletal examination

Musculoskeletal examination The nurse notes the size and shape of the bones and strength of the muscles during the musculoskeletal examination. The nurse assesses the patient's pulse and murmurs during a cardiovascular examination. The nurse assesses for tenderness and the presence of masses during an abdominal examination. The nurse assesses symmetry, contour, and consistency during a breast examination.

What assessments should the nurse include while examining the chest of an infant? Palpating for skin turgor and muscle tone Observing the chest for signs of retraction Auscultating for bowel sounds in the abdomen Noting movement of the chest with respirations Palpating for the apical impulse and note its location

Observing the chest for signs of retraction Auscultating for bowel sounds in the abdomen Palpating for the apical impulse and note its location The nurse observes the chest for signs of retraction while examining the infant. Retraction of the chest indicates increased use of chest muscles for breathing. Bowel sounds may be heard in the chest and abdomen; therefore, the nurse auscultates the abdomen for bowel sounds. The nurse should palpate for the apical impulse and document its location. This determines cardiac function. The nurse palpates the skin on the abdomen, not on the chest, for skin turgor and muscle tone. The abdomen, rather than the chest, moves with respiration in an infant. Therefore, the nurse notes the movement of the abdomen with respirations. p. 789

During the examination of a patient's heart, the nurse documents "No abnormal thrill." Which assessment did the nurse perform on the patient? Palpation of the precordium Palpation of the apical pulse Palpation of the femoral pulse Palpation of the cervical lymph node

Palpation of the precordium The part of the body over the heart and the lower chest is referred to as the precordium. While palpating the precordium, the nurse assesses for heart murmurs and documents it as "no abnormal thrills" when there are no abnormal pulsations obtained. The nurse palpates the apical pulse while examining the heart. However, apical pulse does not indicate any heaves or abnormal thrill. The nurse palpates the femoral pulse while assessing the inguinal area. The nurse palpates the cervical lymph nodes while assessing the neck to determine lymphadenopathy.

What action does the female nurse take while examining the male genitalia? Ask a male colleague to perform the examination. Perform the assessment with the patient standing. Ask the patient to lie supine on the examination table. Include the assessment with the abdominal examination.

Perform the assessment with the patient standing. The male patient is in a standing position during the examination of the genitalia. The nurse can examine the genitals, uniformity of hair growth, or any signs of infection effectively in this position. The female nurse can perform the examination of the male genitalia and would not ask a male colleague to undertake the assessment. The nurse would not be able to palpate the scrotal contents effectively if the patient is in a supine position. The nurse does not include the examination of male genitalia with an abdominal examination, because the areas are structurally and functionally different.

What does the nurse assess with the help of an ophthalmoscope? Red reflex Blink reflex Pupillary reflex Corneal light reflex

Red reflex The nurse assesses the red reflex by using an ophthalmoscope during an eye examination. A penlight is used to assess the blink reflex, the papillary reflex, and the corneal light reflex.

What is the nurse assessing in a newborn by using the Apgar scoring system five minutes after birth? Hearing ability in the newborn Visual disorders in the newborn Neuromuscular function in the newborn Response of the newborn to extrauterine life

Response of the newborn to extrauterine life The Apgar scoring system is an assessment tool that helps to examine the newborn's heart rate, muscle tone, and other vital signs. This scoring system helps to determine the newborn's ability to adapt to extrauterine life. In order to assess the newborn's hearing ability the nurse would conduct a hearing test but would not use the Apgar scoring system. Visual disorders can be assessed by ophthalmoscopy. Therefore, the Apgar scoring system does not help to determine visual disorders in the newborn. To determine neuromuscular functioning, the nurse would test the stepping reflex and doll's eye reflex in the newborn.

Which methods would trigger the Moro reflex in an infant? Shaking the sides of the infant's crib Startling the infant by making a loud noise Tapping the infant's biceps with a reflex hammer Looking at the infant's eyes with an ophthalmoscope Dropping the infant's head suddenly for a short distance

Shaking the sides of the infant's crib Startling the infant by making a loud noise Dropping the infant's head suddenly for a short distance The Moro reflex is an involuntary response caused by fear. It is triggered by jarring the infant's crib, by any loud noise, or by dropping the infant's head suddenly for a short distance. Tapping lightly on the biceps and examining the eyes under an ophthalmoscope do not cause sudden loss of support. Therefore, these methods do not trigger the Moro reflex. The nurse taps the biceps and the triceps with a reflex hammer to assess the reflexes. Looking at the infant's eyes with an ophthalmoscope tests the red reflex.

The student nurse is examining the external genitalia in a female patient under the supervision of the nurse. Which action of the student nurse needs correction? Draping the patient appropriately before starting the procedure Positioning the patient in the lithotomy position on the examination table Sitting on a stool near the foot of the table to perform speculum examination Sitting on a stool near the foot of the table to perform bimanual examination

Sitting on a stool near the foot of the table to perform bimanual examination Sitting on a stool near the foot end of the examination table makes it difficult for the nurse to perform the bimanual examination. Therefore, the nurse stands while performing a bimanual examination of the patient's genitalia. The nurse should drape the patient appropriately to maintain her privacy. The lithotomy position ensures proper exposure of the external genitalia in females; therefore, it is necessary to position a female patient in the lithotomy position while assessing the external genitalia. While performing the speculum examination, the nurse sits on a stool near the foot of the table to ensure proper examination.

While examining a newborn, the nurse inspects the trunk incurvation reflex. What body part is the nurse assessing by doing this? Lower limbs Upper limbs Genital organs Spinal column

Spinal column The trunk incurvation reflex assesses the spinal column. In order to assess the development of the lower limbs, the nurse would note the range of motion and muscle tone and test for the presence of the Ortolani sign in the newborn. The nurse would inspect the genital organs of the newborn in order to determine genital development. The nurse would count the fingers and palmar creases and check for the presence of the grasp reflex and scarf sign in the newborn in order to check development of the upper limbs.

What does the nurse assess when lightly palpating an infant's abdomen? Kidneys Spleen tip Muscle tone Urinary bladder Presence of a mass

Spleen tip Muscle tone Urinary bladder The nurse assesses the tip of the spleen, the muscle tone, and the urinary bladder while lightly palpating the abdomen. Deep palpation helps the nurse to identify the kidneys and the presence of any abnormal masses in the abdomen.

The health care provider has prescribed an occult blood test for a patient. Which specimen does the nurse collect for the test? Blood Urine Stool Mucus

Stool An occult blood test is performed to assess for blood in the feces, which is not visible to the eye. The nurse collects the patient's stool specimen for performing the occult blood test. The nurse collects the blood samples for assessing the components of the blood such as glucose, creatinine, calcium, and magnesium. The nurse collects the urine sample to assess the pH, and to assess for the presence of proteins and nitrates in the urine. If the patient has a throat infection, the nurse collects the mucus sample to assess for the presence of a bacterial or viral infection.

The nurse is performing breast examination on a female patient. Which position of the patient does the nurse find most suitable during the assessment? Prone position Supine position Sitting position Lithotomy position

Supine position While performing breast examination on a female patient, the nurse assists the patient to assume a supine position with the head raised at an angle of 30 degrees. This position is most suitable because it is comfortable for the patient and the patient's breasts are well exposed. The prone position is suitable when the nurse performs back examination and assesses the extension of the hip joint in the patient. The nurse finds the sitting position feasible while examining the lower extremities in the patient. Similarly, the nurse finds the lithotomy position suitable when performing vaginal, rectal, and pelvic examinations in the patient.

How does the nurse record the size and placement of skin lesions? Take a photograph of the lesion. Write down the disease that caused the lesion. Use comparisons to everyday items such as coins. Draw a diagram or picture of the lesion and landmarks. Write a detailed description of the lesion into the record.

Take a photograph of the lesion. Draw a diagram or picture of the lesion and landmarks. Write a detailed description of the lesion into the record. Photographs may be taken if consent is obtained. The nurse may draw a diagram or picture of the lesions to record the location. The nurse may record a detailed description of the lesions using standard terms to describe primary and secondary lesions according to size and location. Comparing the lesions with everyday items will not help in understanding the nature of the lesions effectively, because the comparison may be interpreted differently by different health professionals. The nurse should describe the size and location of the lesion using standard terms; a medical diagnosis will not adequately describe the size and location.

The nurse is examining a patient. Which findings documented by the nurse are considered normal? The gag reflex is present. S3 and S4 heart sounds are absent. The uvula is deviated to the left side during phonation. Apical pulse is present in the seventh intercostal space. Tympanic percussion note is present in the left upper quadrant of the abdomen.

The gag reflex is present. S3 and S4 heart sounds are absent. Tympanic percussion note is present in the left upper quadrant of the abdomen. The gag reflex is present normally in human beings. The absence of a gag reflex suggests that the patient has difficulty in swallowing and is at risk of aspiration. S3 and S4 heart sounds are normally absent. The presence of these heart sounds indicates that the patient has heart pathology. The left upper quadrant of the abdomen contains the stomach, which is an air-filled vessel. Percussion of the stomach region yields a tympanic percussion note. The uvula should be raised at the midline during phonation. Apical pulse is normally obtained in the fifth intercostal space.

What would the nurse assess using a speculum during the examination of the nose? The external nose The nasal septum The nasal mucosa The nasal turbinates The patency of the nostrils

The nasal septum The nasal mucosa The nasal turbinates The nurse uses the speculum to inspect the internal part of the nares, which includes the nasal septum, nasal mucosa, and the nasal turbinates. The nurse can assess the patient's external nose by performing visual inspection; it does not require any special instrument. The nurse can assess the patency of the nostrils by observing the patient while the patient breathes through each nostril.

While caring for a newborn, the student nurse observes that the newborn starts crying and extends the legs, arms, and fingers when there is a loud noise. What should the nurse understand from newborn's behavior? The newborn has a grasp reflex. The newborn has a startle reflex. The newborn has a triceps reflex. The newborn has a Babinski reflex.

The newborn has a startle reflex. The startle reflex is triggered by a loud noise, which causes the newborn to cry and extend the arms and legs. If the newborn holds the nurse's finger after the nurse firmly places it on the newborn's palm, then it indicates that the newborn has a grasp reflex. If the newborn stretches his or her leg when the nurse taps the triceps tendon with a reflex hammer, it indicates that the newborn has a triceps reflex. If the newborn turns the foot and flares the toes after the nurse applies a gentle stroke on the outer side of the newborn's sole, it indicates that the newborn has a Babinski reflex. p. 790

The nurse is planning to test the functioning of the extraocular muscles in a patient with vision problems. Which interventions does the nurse perform during the test? The nurse darkens the room. The nurse checks the corneal light reflex. The nurse uses the confrontation technique. The nurse assesses with an ophthalmoscope. The nurse asks the patient to perform the six cardinal positions of gaze.

The nurse checks the corneal light reflex. The nurse asks the patient to perform the six cardinal positions of gaze. The corneal light reflex is used for assessing the symmetric movement of the eyes. The nurse uses corneal light reflex to assess for strabismus, which is caused by extraocular muscle dysfunction. The nurse asks the patient to perform the six cardinal positions of gaze to assess the functioning of the extraocular muscles in a patient with vision problems. Darkening the room, using the ophthalmoscope, and using the confrontation technique are not required for the assessment of extraocular muscle dysfunction. The nurse darkens the room to assess the pupillary light reflex in the patient. The nurse uses an ophthalmoscope to assess the red reflex and inspect disc, vessels, and retinal background. The nurse also uses the confrontation technique to evaluate the visual fields stimulated by cranial nerve II or the optic nerve.

The nurse is completing a detailed assessment of a patient. Which data obtained from the patient would the nurse document under the functional assessment? The patient is a high school graduate. The patient wakes up daily at 7:00 AM. The patient does not have any allergies. The patient skips breakfast most of the time. The patient had a motor vehicle accident 3 years ago.

The patient is a high school graduate. The patient wakes up daily at 7:00 AM. The patient skips breakfast most of the time. Functional assessment includes the assessment of self-concept, activity and exercise, and nutrition. Education plays a major role in the development of self-concept. Therefore, the nurse documents the patient's education level under functional assessment. The assessment of activity and exercise includes the assessment of the daily routine, which the patient follows. If the patient wakes up daily at 7:00 AM, it should also be documented under functional assessment. Skipping breakfast is also an unhealthy nutritional habit. Thus, the nurse should document this finding in the functional assessment of the patient. The absence of allergies should be documented under the past health history of the patient. The patient had a motor vehicle accident 3 years ago; this information should also be documented in the patient's past health history.

The nurse is performing a well-child examination in a preschooler. What should the nurse include to provide effective care for the child? Not converse with the child throughout the examination Thoroughly explain all the steps of the examination to the child Ask the child to blow on a pinwheel to listen to the lung sounds Ask the child to stand on one foot and build a tower with blocks Not ask the child to remove the underpants to examine the genitalia

Thoroughly explain all the steps of the examination to the child Ask the child to blow on a pinwheel to listen to the lung sounds Ask the child to stand on one foot and build a tower with blocks While assessing the preschooler, the nurse should make the child feel comfortable and should follow appropriate interventions to provide effective care. The child may feel anxious and may not participate in tests because of fear. To reduce any fear and anxiety, the nurse should explain all steps of the examination to the child before beginning the assessment. The nurse can give a pinwheel to the child and ask the child to blow on it in order to determine pulmonary functioning. In order to assess fine and gross motor skills in the child, the nurse would ask the child to stand on one foot and build a tower. The nurse should talk with the child about school, friends, and family. This makes the child feel comfortable and helps the nurse to evaluate the child's social interactions. A preschooler may not feel uncomfortable undressing in front of strangers and would remove the underpants without hesitation. Therefore, in order to examine the genitals, the nurse can ask the child to remove his or her underpants.

While examining the lower extremities of an infant, the nurse checks for abnormalities in the infant's toes. What could be the reason behind this nursing intervention? To assess for the presence of syndactyly To assess for the presence of the grasp reflex To assess for the presence of the Ortolani sign To assess for the presence of the Babinski reflex

To assess for the presence of syndactyly The nurse would check an infant's toes to assess for the presence of syndactyly. In order to find the Ortolani sign, the nurse would flex the infant's hip and adduct the infant's thigh. This intervention would help the nurse to assess hip displacement in the infant. In order to test the Babinski reflex, the nurse would gently stroke the infant's sole and would look for fanning of the toes. In order to assess for the presence of the grasp reflex, the nurse would stimulate the infant's palm by pressing it with a finger or an object such as a rattle.

While assessing the genitalia of a male patient, the nurse finds a hard mass on palpation of the scrotal sac. Which intervention should the nurse perform in this situation? Transilluminate the scrotal sac. Check for the presence of Romberg sign. Prepare the patient for surgery immediately. Report immediately to the health care provider.

Transilluminate the scrotal sac. Transillumination refers to the shining of a light through a body area or organ to check for abnormalities. The nurse palpates the scrotal sac or its contents while performing genital examination in a male patient. If the nurse finds the presence of any mass in the scrotum upon palpation, the nurse should transilluminate the scrotal sac to confirm the presence of a lump. A Romberg test is done for the assessment of balance. The nurse should perform transillumination before reporting to the health care provider. The nurse should prepare the patient for surgery only if the health care provider has scheduled the surgery.

Cranial Nerve XI

ah accessory m

nasal patency

a measure of how open the nose is, and it is not equivalent to airflow or resistance to airflow

Crainial Nerve IX

good glossopharyngeal b

Cranial Nerve XII

heaven hypoglossal m

syndactyly

is a condition wherein two or more digits are fused together

Cranial Nerve III

oh oclomotor m

Crainal Nerve I

oh olfactory s

Cranial Nerve II

oh optic s

Ortolani sign

part of the physical examination for developmental ... A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum