Health assessment exam 2

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding?

Correct response: Coarse crackles Explanation: Coarse crackles are low-pitched bubbling moist sounds that are described as separating Velcro. Fine crackles are high-pitched, short, popping sounds heard during inspiration and not cleared with coughing. Sibilant wheezes are high-pitched musical sounds. Sonorous wheezes are low-pitched snoring or moaning sounds.

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Correct response: Referral for further assessment of thyroid function Explanation: A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

High

The nurse assesses the frontal sinus where?

above the eyes

The middle layer of the eye is known as the

choroid layer.

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.

Which vessel is the nurse assessing if the major artery of the neck is being examined?

Correct response: Carotid Explanation: The common carotid artery exits the aorta and extends upward in the neck to branch into the internal and external carotid arteries. It is the major artery carrying blood to the brain. The internal jugular veins are located in the neck. The temporal artery is located between the top of the ear and the eye. The radial artery is located at the wrist.

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

Correct response: One deep inspiration and expiration through the open mouth Explanation: Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth.

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?

Correct response: "Cover one of your eyes and then read out the letters on the chart, starting from the top." Explanation: Using a Snellen chart requires that the client stand a specific distance from the chart, usually 20 feet. The client does not move, and each eye is assessed individually.

A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?

Correct response: "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Explanation: Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted clients; no additional follow-up is needed.

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?

Correct response: Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect what health problem?

Correct response: Otitis externa Explanation: A tender tragus is associated with otitis externa. Tenderness behind the ear would suggest otitis media. A ruptured tympanic membrane would be associated with ear pain and a popping sensation. Tenderness over the mastoid process would suggest mastoiditis.

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available?

gloves penlight tongue depressor

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules. Freckles are flat, small macules of pigment that appear following sun exposure.

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Correct response: Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The client's statement most likely suggests that he has what diagnosis?

Correct response: Presbycusis Explanation: Presbycusis, a gradual hearing loss that often begins with a loss of the ability to hear high-frequency sounds, is common after age 50. Vertigo refers to a true spinning motion. Otalgia refers to ear pain. Tinnitus refers to ringing in the ears.

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown?

Correct response: Skin that feels boggy on palpation Explanation: Boggy skin consistency indicates a stage 1 pressure ulcer. Eschar and skin loss to the dermis would be noted in a more severe pressure ulcer; excessive sweating may constitute a risk factor but is not necessarily a sign of skin breakdown.

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease?

Correct response: assessing the client's hard palate with a bright light Explanation: The nurse should not confuse a normal scleral yellow pigmentation in dark-skinned individuals with jaundice. Rather, the nurse should observe the hard palate with a bright light for jaundice. While it is appropriate to assess for jaundice in the locations identified by the other options, the techniques described are incorrect.

Straight movements of the eye are controlled by the

Correct response: rectus muscles. Explanation: The extraocular muscles are the six muscles attached to the outer surface of each eyeball. These muscles control six different directions of eye movement. Four rectus muscles are responsible for straight movement, and two oblique muscles are responsible for diagonal movement.

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should

Correct response: refer the client to a physician for further evaluation. Explanation: The trachea may be pulled to the affected side in cases of large atelectasis, fibrosis or pleural adhesions. The trachea is pushed to the unaffected side in cases of a tumor, enlarged thyroid lobe, pneumothorax, or with an aortic aneurysm.

The nurse asks a client to say "ah" while depressing the tongue with a wooden tongue blade. What is the nurse assessing when performing this technique?

Correct response: vagal nerve function Explanation: When asking for a client to say "ah" the nurse assesses for the rise of the soft palate and the uvula which is a test of CN X (the vagal nerve) function. Leukoplakia, a white coating, is visible on the tongue and buccal mucosa and would not need to be assessed by asking the client to say "ah." Evaluating the tongue for symmetry assesses CN XII (hypoglossal nerve) function. An aphthous ulcer would be present on the tongue, lips or buccal mucosa and would not need to be assessed by asking the client to say "ah."

The client comes to the clinic with complaints of a sore throat, difficulty swallowing, malaise, and anorexia. Upon examination, the nurse notes a red throat with enlargement of the tonsils and jaw and neck lymph nodes. Which condition does the nurse suspect the client has?

Strep

Which vision acuity reading indicates blindness

orrect response: 20/200 Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision.

Hearing

1. External ear channels sound waves through TM 2. To inner ear ossicles via oval window, then to cochlea 3. Which vibrates receptor hair cells of the organ of Corti 4. Producing electrical impulses for auditory nerve 5. Then delivers impulses to auditory cortex (in brain) 6. Which interprets them as sound, assigns meaning 7. Brainstem locates sound origination

The right lung has how many lobes?

3 lobes (superior, middle, inferior)

Corneal Light Reflex (Hirschberg Test)

Assess the parallel alignment of the eye axes by shining a light toward the person's eyes. Corneal light reflex (Hirschberg): strabismus For saturation of pupils - should be able to see light in same spot in both pupils

During a prenatal class, a participant says that she was told that her breasts are not large enough to breastfeed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which variable?

Correct response: Amount of glandular tissue Explanation: The glandular tissue constitutes the functional part of the breast allowing for milk production. The amount of glandular tissue determines functional capacity of the breast, not the breast size, amount of fatty tissue, or subcutaneous fat layer.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?

Correct response: Asymmetrical shape Explanation: Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.

At which location would a nurse palpate a client's submental lymph nodes?

Correct response: Behind the tip of the mandible Explanation: The submental lymph nodes are located a few centimeters behind the tip of the mandible. The tonsillar nodes are located at the angle of the mandible at the anterior edge of the sternomastoid muscle. The occipital nodes are at the posterior base of the skull. The postauricular nodes are behind the ears.

An Asian American primipara asks to speak with the nurse about a concern she has over potential genetic defects in her fetus. What congenital problem would the nurse expect questions about based on the client's ethnicity?

Correct response: Cleft lip and palate Explanation: Cleft lip and palate have increased incidence in Native and Asian Americans. Down syndrome is not known to be of higher incidence in Asian Americans. Spina bifida would be a concern if the client had not been taking folic acid. Transposition of the great vessels is not known to be of higher incidence in Asian Americans.

A nurse is working with a client who has an impaired ability to smell. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?

Correct response: Cranial nerve I (olfactory) Explanation: Receptors of cranial nerve I (olfactory) are located in the nose. These receptors are related to the sense of smell. Cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and XII (hypoglossal) assist with some functions related to ingestion, taste, preparing food for digestion, and speech.

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?

Correct response: Decreased strength of temporal artery pulsations Explanation: The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests a malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age.

Which of the following muscles is primarily responsible for thoracic cavity enlargement?

Correct response: Diaphragm Explanation: The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity.

The nurse asks the client to perform the action pictured. What is the nurse assessing?

Correct response: Near vision Explanation: The client is using the Jaeger chart which is used to assess near vision. The Snellen chart is used to assess distant vision. The nurse would not assess intraocular pressure. Ishihara cards are used to assess color discrimination.

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?

Correct response: On the client's mastoid process Explanation: For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is placed in the center of the client's forehead or head for the Weber test.

On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

Correct response: Perform both the distant and near visual acuity tests Explanation: The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination.

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

Correct response: Peripheral cyanosis Explanation: Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Correct response: Red, bulging, with an absent light reflex Explanation: A client with acute otitis media would have a red, bulging eardrum, with absent light reflex. A pearly, translucent membrane, with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane, with bubbles is seen in serous otitis media. A gray, translucent membrane, with no retraction is a normal finding in the tympanic membrane

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

Correct response: Sebum production Explanation: Sebum production decreases with age, therefore increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue.

The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?

Correct response: Slightly above the clavicle Explanation: The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib and posteriorly, the base lies at about the tenth rib.

Cultural & environmental:

Gingivitis = inflammation, bleeding of gums Cleft lip, palate (more common in Asian populations) Bifid uvula (more common in Native American populations) Oral and pharyngeal cancers Sleep-disordered breathing

Older at risk for

Glaucoma, cataracts, hypertension,presbyopia

tonsil assessment

Grade 1-4 (4 is touching each other) ask patient if they have had their tonsils taken out.

Lifespan - Older adults:

Gustatory rhinitis = runny nose from smelling/tasting food Decreased... olfactory sensory fibers, saliva production, number of taste buds Edentulous = toothless Teeth - discoloration, loosening Receding gums Tongue - either smooth and shiny in appearance, or fissured

thyroid gland

Hard to palpate unless inflamed

Older adults assessment

Hearing aids?? Hearing loss Vertigo Tinnitus Otalgia-ears pain Ear infections

The thoracic cavity contains which of the following organs? Select all that apply.

Heart Lungs Most of the esophagus

A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?

Lymphadenopathy of infectious origin Explanation: An enlarged lymph node resulting from infection is generally hot, tender, and red. Close examination of the skin that drains to that lymph node region is advised. Often there will be a cut or scratch over the involved arm that has an infectious agent. An example is cat scratch disease.

Urgent Ear Assessment

Outer ear foreign object: refer otolaryngologist for removal Foul-smelling drainage: immediate attention Chronically draining ears Cholesteatoma - Can erode auditory ossicles leading to significant hearing damage Ear trauma - Hemotympanum, tympanic rupture

The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. What would the nurse expect to find?

Red and scaling on the areola

kinetic confrontation

Same process as above, but examiner presents fingers from further peripherally toward center of each quadrant, wiggling them until client reports when he/she can see them. Fingers should not be immediately visible (except in inferotemporal quadrant). Client should see fingers at about same time as the examiner. Compares visual field of client to that of examiner, which is assumed to be within normal limits. Kinetic confrontation - for assessment of peripheral vision Cover 1 eye, ask when they see movement If somebody's going to confront you, they'll up from behin

lymphatics system

a major part of the immune system, job is to detect and eliminate foreign substances from the body; vessels follow clear, watery fluid (lymph) from tissue spaces into circulation 1) Filter potential pathogens from the body (if inflamed, sign of infection. If hard and immoveable - concern for serious infection, chronic illness, or cancer!) 2) Drain fluid that has moved outside of circulation back into the vessels Major chains of lymph nodes in neck: Preauricular, postauricular, occipital Superficial cervical, deep cervical, posterior cervical, Submental and submandibular Should be less than <1cm, moveable, soft

cover test

an examination of how the two eyes work together and is used to assess binocular vision. one eye at a time is covered while the patient focuses on an object across the room. Cover test: ocular deviation To test muscles, deviation of one eye or another (lazy eye)

Reference lines lateral

anterior axillary line midaxillary line posterior axillary line

epistaxis

bleeding from the nose

Abrupt loss of smell could be a ________ ________

brain tumor

Normal breath sounds

bronchial, bronchovesicular, vesicular

Snellen chart

chart used for testing visual acuity; contains letters of varying sizes and is shown from a distance of 20 ft; avg person who can read at this distance is said to have 20/20 vision

While interviewing a client, the nurse asks her what her typical daily diet consists of. Which of the following is associated with an increased risk for breast cancer?

high fat diet

cardinal fields of gaze

how to test CN's III, IV, VI misalignment, uncoordinated eye movements Watch finger or pen light in 6 cardinal directions without moving head Should be simple, flowing, no twitching (nystagmus), should be able to track

When examining the breasts of a client, the nurse finds a collection of fatty tissue that appears as a lump. The nurse knows that this is which of the following conditions?

lipoma Limas are a collection of fatty tissue that may also appear as a lump. Milk cysts are sacs filled with milk. Fibroadenomas are usually 1-5 cm, round or oval, mobile, firm, solid, elastic, nontender, single or multiple benign masses found in one or both breasts. Malignant tumors, or carcinomas, are most often found in the upper outer quadrant of the breast. They are usually unilateral, with irregular, poorly delineated borders. They are hard and nontender and fixed to underlying tissues

During the physical examination of a female client, the nurse notes that the client's axillary lymph nodes are enlarged, hard, and fixed. The nurse recognizes that these findings are consistent with what disease process?

malignancy

The nurse observes a white patchy area in the pharyngeal fossa of a client. What is the nurse's best action?

orrect response: Prepare client for a biopsy of the lesion. Explanation: The pharyngeal fossa is the most common site of oral cancer. A whitish area is a suspicious finding and will likely be biopsied. Gargling with saline and antibiotics are not recommended. This finding does not indicate a need for a tonsillectomy. Indications for tonsillectomy are repeated tonsillitis and/or tonsil hypertrophy.

Anterior Thoracic Landmarks

suprasternal notch, sternum, sternal angle, costal angle

apex

the highest point

accomidation

the process by which the eye's lens changes shape to focus near or far objects on the retina

Lifespan consideration ears

Continual cartilage formation → increased ear prominence the older we get Fine hairs become coarser, stiffer → sound wave interference → decreased hearing Cerumen (earwax) impaction → decreased hearing Slowing of electrical responses in brain means increased reaction time needed

A nurse in the operating room has a client who just underwent gastric bypass surgery and weighs 243 kilograms (534.6 pounds). Upon extubation, the client's oxygen saturation drops to 84% and the client has difficulty catching her breath. What could be causing these problems?

Obesity, which can limit chest wall expansion and compromise breathing

color vision

Ishihara cards

Risk factors for nose, sinus, mouth, throat

Tobacco use (smoking) Allergies Topical decongestant use Sleep disorders Cancer - HPV linked to head and neck cancers Oral health Hereditary hemorrhagic telangiectasia (chronic nosebleeds

adventitious breath sounds

Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles.

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 passing through constricted passageways. Wheezes appear when air passes through constricted passages. Wheezes are not the result of diversion of air to the bronchi, increased turbulence, or air entering the pleural space.

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

external eye structures

Lacrimal apparatus; Bulbar conjunctiva Sclera; cornea; lens

Reference Lines - Anterior

Midsternal line, midclavicular line, anterior axillary line

neck

Neck (C1-C7) Trachea - centered Thyroid, parathyroid glands - centered, behind, hard to palpate unless inflamed (problem) Lymphatics

Sensorineural hearing loss: problem from inner ear to auditory cortex

Presbycusis- loss of hearing as we age Tinnitus= ringing in the ear without external sounds

What to do for a nose bleed

pinch soft part of nose and tilt head forward

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

repeat the phrase "ninety-nine."

Posterior Thoracic Landmarks

vertebra prominens, spinous processes, inferior border of scapula, twelfth rib

Reference Lines - Posterior

vertebral line scapular line

otoscopic evaluation

visual inspection of the canal and eardrum Adults= up and back Children= down and back

Risk factors for hearing loss

-age (increases after 50) -environmental noises -ototoxic medications -family history -autoimmune disorders -history of congenital hearing loss Frequent ear infections Exposure to smoke Environmental factors that increase risk for otitis media include: Secondhand smoke Propping bottles for babies to feed Bottle feeding in supine position

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds Equilibrium

Weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. differentiates unilateral hearing loss Put tuning fork on top of skull, middle of forehead - midline Should be able to hear it on both sides equally Tests sensorineural hearing loss

whisper test

Test in which an examiner whispers a sentence and asks the patient to repeat it to evaluate loss of high-frequency sounds.

Upon inspection of a client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding?

This is often a normal finding in the Native American population.

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

Unequal expansion of the chest Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest. Crepitus on palpation can be found in clients with an open thoracic injury or with a tracheostomy. Sunken sternum and adjacent cartilages are seen in funnel chest. Retraction of intercostal spaces occurs in labored breathing.

The submandibular glands open under the tongue through openings called

Wharton ducts

Jaeger chart

a chart for testing near vision. Near vision: 14 inches from face

Meneire's Disease

chronic inner ear disease; too much fluid in the Labyrinth Meniere disease = vertigo + tinnitus + unilateral hearing loss Exacerbation periods often last 24 hours followed by periods of remission Idiopathic

Altered breath sounds

coarse; diminished/decreased; absent; stridor

Which characteristic would support the determination that a client is at high risk for breast cancer?

first degree relative with a history of either BRCA1 or BRCA2 mutation

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis

has a watery, mucoid discharge.

Rinne test

hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction Put tuning fork on mastoid process, they stop hearing it → move to air conduction, they can hear again Can indicate blockage Tests conductive hearing

A client is diagnosed with a stage IV pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.

client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status?

A) The client will have a loss of involuntary respiratory control.

The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurologic deficits Explanation: Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for client's with brain damage?

Biot's respirations In people with irritation or brain damage, the respiratory pattern will be irregular and characterized by varying depth and rate followed by periods of apnea. Cheyne-Stokes is a regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Retractive is not an observable pattern of respirations. Kussmaul is seen in clients with diabetic ketoacidosis and are characterized by deep but rapid respirations similar to hyperventilation.

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

Correct response: "Do you experience any ringing, roaring, or crackling in your ears?" Explanation: Ringing in the ears (tinnitus) may be associated with excessive ear wax buildup, high blood pressure, or certain ototoxic medications. None of the other questions pertains to conditions related to high blood pressure. Ear pain is associated with ear infections, cerumen blockage, sinus infections, teeth and gum problems, and swimmer's ear. Drainage usually indicates infection. Hearing loss may be related to any number of causes but is not associated with high blood pressure.

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question?

Correct response: "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays." Explanation: The sun protective factor or SPF is a ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B sunrays. None of the other options present correct information regarding the meaning of SPF 15.

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

Correct response: 4+ Explanation: The nurse should document the tonsillar grading as 4+ because the tonsils are so large that they are touching one another. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones that are barely visible. Tonsils that touch the uvula are graded 3+.

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?

Correct response: Assess the nasolacrimal sac Explanation: Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

Correct response: C7 Explanation: The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?

Correct response: Can be caused by an underlying systemic illness Explanation: Diseases or disorders of the nails can be a local problem or they may be a sign of an underlying systemic disease that needs to be assessed. A nurse should be sensitive when interviewing a client with nail problem because they can be damaging to a person's self image. A nurse should ask questions in a nonjudgmental manner if the client has abnormalities of the nails that are due to poor hygiene.

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

Correct response: Chronic obstructive pulmonary disease (COPD) Explanation: This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option.

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Correct response: Compressing the arteries bilaterally Explanation: The nurse needs to avoid bilateral compression of the carotid blood vessels to prevent reducing the blood supply to the brain. The nurse does not need to avoid having the client flex the neck, ask the client to swallow water, or perform the exam while the client is seated.

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?

Correct response: Consensual response Explanation: When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light in one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict.

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Correct response: Equalizes the pressure in the middle ear with atmospheric pressure. Explanation: The eustachian tube opens during swallowing or yawning. Its function is to equalize the pressure in the middle ear with atmospheric pressure so that there is equal pressure on both sides of the tympanic membrane to allow the drum to vibrate freely. The stapes transmits the vibration to the fluid-filled inner ear at the oval window. The vestibule sends information to the cerebellum and the midbrain. The tympanic membrane separates the external from the middle ear.

Which finding should a nurse recognize as normal when assessing the ears of an elderly client?

Correct response: High-tone frequency loss Explanation: Presbycusis, a gradual hearing loss, is common after the age of 50 years. It begins with a loss of the ability to hear high-frequency tones. Cerumen production may increase in older age or become drier and build up as the cilia become more rigid. The earlobes become elongated in older age. A bulging tympanic membrane is not a normal finding at any age.

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse?

Correct response: Hypoxia Explanation: When the capillary refill is greater than 2 seconds, a respiratory or cardiovascular disease should be considered as causing hypoxia. This finding does not indicate an infection or a vitamin C deficiency. This is not a normal finding.

The nurse is performing an ear assessment of an adult client. Which action constitutes the correct procedure for using an otoscope when examining the client's ears?

Correct response: Inserting the speculum down and forward into the ear canal Explanation: The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used.

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

Correct response: Macule Explanation: A macule is a flat, non-palpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on it size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Correct response: Narrowing or partial obstruction of an airway passage Explanation: The auditory characteristics of wheezing result from narrowing of the lumen of a respiratory passage. Fluid in the alveoli results in crackles, and complete obstruction causes an absence of breath sounds. Decreased lung compliance compromises ventilation but does not necessarily result in wheezes.

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as what?

Correct response: Normal tympanic membrane Explanation: The tympanic membrane is normally a pearly gray color with a shiny appearance. White spots would indicate scarring. A yellowish bulging membrane would suggest serous otitis media; a red bulging membrane would suggest acute otitis media. Otitis externa does not directly affect the appearance of the tympanic membrane.

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

Correct response: On each side between the top of the ear and the eye Explanation: The temporal artery is located between the top of the ear and the eye. The submandibular glands are located inferior to the mandible, underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The internal jugular and carotid arteries are located bilaterally, parallel and anterior to the sternomastoid muscle.

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?

Correct response: On the mastoid process Explanation: For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is place in the center of the client's forehead or head for the Weber test.

When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?

Correct response: Optic disc Explanation: The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision.

A 25-year-old accountant presents to the clinic with intermittent lower right-sided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some acetaminophen and put a heating pad on his side, but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married with a baby due in 2 months. He denies any smoking or illegal drugs. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender. What disorder of the chest best describes his symptoms?

Correct response: Pleural pain Explanation: This pain is sharp and knifelike and occurs over the affected area of pleura. Breathing deeply usually makes the pain worse, whereas lying quietly on the affected side makes the pain better. Pleurisy often occurs from inflammation due to an infection, neoplasm, or autoimmune disease.

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

Correct response: Presbyopia Explanation: Presbyopia is indicated when the client moves an object away from the eyes to focus. It is a common condition in clients over age 45. Myopia is impaired far vision. Cataracts typically are associated with painless blurring, light sensitivity, poor night vision, and a need for a brighter light to read. Tropia refers to a misalignment of the eyes.

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Correct response: Purpuric Explanation: Purpuric lesions are deep red or purple in color that fades to green, yellow, or brown over time. They can range in size from 1 mm to greater than 3 mm and can be round or oval in shape. Vascular lesions range in size from 1 mm to 2 cm. Their color ranges from fiery red to blue. Their shape can be round, flat, raised, and have radiating legs. Primary skin lesions can be flat, raised, or fluid filled. They can be of various colors, shapes, and textures. Secondary skin lesions can have crusts, lichenification, or scars. They can also be described as erosions, excoriations, fissures, or ulcers.

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?

Correct response: Red, swollen, with purulent discharge Explanation: The nurse should find red, swollen nasal mucosa with purulent discharge in the client diagnosed with upper respiratory tract infection. Dark pink, moist nasal mucosa which is free of exudate is a normal finding. Pale pink, swollen nasal mucosa with watery exudate and bluish gray, swollen nasal mucosa with watery exudate is found in cases of allergy.

After conducting a health history, the nurse decides to perform the assessment shown. What finding did the nurse use to make this clinical determination?

Correct response: Reduced hearing in one ear Explanation: The Weber test is used to determine unilateral hearing loss. With conductive hearing loss, the client reports hearing the tuning fork sound better in the poor ear. With sensorineural hearing loss, the client hears the sound better in the good ear. The Weber test is not used to assess a sore throat. There are many reasons for a rigid tympanic membrane. A Weber test is used to test for hearing only. This test will not help diagnose the reason for edematous neck lymph nodes.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

Correct response: Risk for Injury Explanation: The only nursing diagnosis that can be confirmed with this data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnosis.

A nurse should assist a client to assume what position in order to best assess the mouth, nose, and sinuses?

Correct response: Sit with the head erect and at the eye level of the nurse Explanation: The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner. Tilting the head backwards and a Semi-recumbent position with the chin lifted will make it more difficult to visualize the mouth and nose. The prone position will make transillumination & palpation of the sinuses more difficult for the examiner.

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

Correct response: Skin warm and dry to the touch Explanation: Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

Correct response: Sternomastoid Explanation: The superficial cervical nodes are in the area superficial to the sternomastoid muscle, whereas the deep cervical chain is deeply within and around it. The supraclavicular nodes lie deeply between the clavicles and sternomastoid muscle.

A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?

Correct response: Subconjunctival hemorrhage Explanation: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turns yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rare for a serious condition to cause it, so reassurance is usually the only treatment necessary.

Which of the following would the nurse document as an abnormal finding with lymph node assessment?

Correct response: Tender Explanation: A lymph node that is tender is an abnormal finding suggesting acute infection. Size less than 1 cm, mobile, and discrete indicate normal findings.

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test?

Correct response: The client has unilateral hearing loss. Explanation: Unilateral hearing loss is the major indication for Weber's test, which helps distinguish between conductive hearing and sensorineural hearing. Older age, infection, and a history of stroke are not specific indications for this test.

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?

Correct response: This could be a sign of dehydration Explanation: A depressed fontanel may indicate dehydration. This is not a normal finding and does need further assessment. A depressed fontanel does not indicate increased intracranial pressure, possible neurological disorder, or a sign of physical abuse.

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?

Correct response: Vasoconstriction Explanation: Peripheral cyanosis may be a local problem resulting from vasoconstriction. A cardiopulmonary etiology is unlikely in a client who enjoys overall good health.

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?

Correct response: acute bacterial sinusitis Explanation: Acute bacterial sinusitis should be suspect if there is a recent history of upper respiratory tract infection. The sensitivity for the symptom correlation of upper respiratory tract infections is 90%, and the specificity is 80%. Headache and tenderness on palpation of the sinuses are also features acute bacterial sinusitis. Allergic rhinitis is not associated with an infectious process. Nasal congestion that results from triggering allergens, usually environmental, is the cause. Rhinitis medicamentosa results from excessive use of decongestants used to treat a nonbacterial nasal congestion. Epistaxis is a condition that occurs when the mucosa of the nares is eroded and exposed vessels break leading to what is commonly called a nosebleed. Tenderness and headache are not associated features of epistaxis.

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

Correct response: areola of the breast. Explanation: The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

Correct response: fissures. Explanation: Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot.

When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals?

Correct response: fundus is grayish brown with a purplish cast Explanation: An eye assessment of a dark-skinned person would include the grayish brown, almost purplish cast to the normal fundus. The remaining options are noted in an eye assessment of the normal fundus of a fair-skinned person.

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

Correct response: hyperthyroidism Explanation: The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash?

It is likely to be related to her lupus.

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Stage II Explanation: A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

The right lung has three lobes, while the left lung has two lobes. The right lung is made up of three lobes, whereas the left lung contains only two lobes. The sizes of the lungs are not identical but do not differ by one-third. The lower lobes of both lungs are primarily located toward the posterior surface of the chest wall.

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include?

Thoroughly chew small amounts of food with each mouthful.

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

Up The correct technique to use when examining a client's sclera and conjunctiva during an eye examination is to instruct the client to look up. Having the client look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination.

Cranial nerves associated with eye movement

III Oculomotor IV Trochlear VI Abducens

Allen test

test that determines the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery

apex of the heart

lower tip of the heart

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

A client has been found to have a breast lump and an ultrasound has been ordered. The client voices concerns to the nurse she is afraid of the painful testing she is going to endure. How should the nurse best respond?

"This noninvasive test uses high frequency waves to determine if the mass is solid or cystic."

Which of the following is true regarding self breast examination?

A high proportion of breast masses are detected by self breast examination.

A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status?

A) The client will have a loss of involuntary respiratory control.

The Kiesselbach plexus is the most common site for what?

Anterior nosebleeds

A nurse is inspecting a client's breasts. The nurse notices that one breast is larger than the other. Which action should the nurse take next?

Ask the client whether the larger breast has increased in size recently

hearing difficulties

Conductive hearing loss: sound wave transmission disrupted through external or middle ear External ear blockage: clear obstruction Middle ear: investigate for pathology Conductive loss overcome by increased amplitude

Fibrous tissue that provides support for the glandular tissue of the breasts is termed

Cooper ligaments The fibrous tissue provides support for the glandular tissue largely by way of bands called Cooper's ligaments (suspensory ligaments). These ligaments run from the skin through the breast and attach to the deep fascia of the muscles of the anterior chest wall.

Assessment of extraocular muscle movements

Corneal light reflex (Hirschberg) Cover test Cardinal fields of gaze

The nurse is beginning the inspection of a young adult client's breasts. The client states, "My left breast has always been a bit bigger than the right." How should the nurse best respond to the client's statement?

Correct response: "Many women have this, and it's rarely a sign of a health problem." Explanation: Slight breast asymmetry very rarely signals a health problem unless it represents a sudden change. Referral is unnecessary, and it will not usually resolve with age or weight loss.

A client has presented for care to the clinic, stating, "I'm pretty sure that I feel a new lump in my breast." After confirming the presence of a lump, what action should the nurse take next?

Correct response: Arrange for a prompt referral to her primary care provider. Explanation: Any lumps should be assessed further, and the client should be referred to a physician. It would be inappropriate to take a "wait and see" approach without a referral. Admission to the emergency department is not necessary.

The nurse is performing the technique shown. What is the nurse assessing?

Correct response: Chest expansion Explanation: The nurse is assessing for lung symmetry when the hands are placed equidistant on the posterior chest. A stethoscope is needed to assess breath sounds. The client repeats a word when tactile fremitus is assessed. Percussion is used to assess for tissue consolidation.

During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus?

Correct response: Decreased Explanation: The nurse should find decreased fremitus in the client diagnosed with pneumothorax. Fremitus is the vibration of air in the bronchial tubes transmitted to the chest wall which is normally symmetrical. Unequal fremitus can be increased or decreased as a result of consolidation, bronchial obstruction, air trapping due to emphysema, pleural effusion, or pneumothorax. Absence of fremitus is not a physiological finding.

While examining a client's breasts, a nurse notices milky discharge from the nipple. The client explains that she recently had a baby and is currently breastfeeding. The nurse understands that which type of tissue in the breast is responsible for allowing milk production?

Correct response: Glandular Explanation: Glandular tissue constitutes the functional part of the breast, allowing for milk production. The fibrous tissue provides support for the glandular tissue largely by way of bands called Cooper's ligaments (suspensory ligaments). Fatty tissue provides most of the substance to the breast and thus determines the size and shape of the breasts. Lymphatic tissue, which forms lymph nodes, is responsible for draining lymph from the body.

The nurse is assessing a 15 year old male and finds soft, fatty enlargement of breast tissue. The nurse would document this as what?

Correct response: Gynecomastia Explanation: Gynecomastia is breast enlargement. Cysts are lumps that may be found in the breasts. Abscesses are an infection. Fibroadenoma is a well-defined , usually single or multiple, nontender, firm or rubbery, round or lobular mass that is freely movable.

The nurse notes that a client's left breast feels significantly warmer than the right breast. What should the nurse consider is occurring with this client?

Correct response: Inflammation Explanation: Heat in the breasts of a client who has not given birth or lactating indicates inflammation. This finding is not associated with breast cancer or fibrocystic breast disease. Extramammary ducts are visible and not associated with warmer skin temperature over the breast.

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Correct response: Instruct the client to cough forcefully Explanation: When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress.

A nurse is examining the breasts of a woman who has had a mastectomy. Which of the following should the nurse do?

Correct response: Palpate the scar for redness, lesions, lumps, swelling, or tenderness Explanation: If the client has had a mastectomy or lumpectomy, it is still important to perform a thorough examination. Palpate the scar and any remaining breast or axillary tissue for redness, lesions, lumps, swelling, or tenderness. White scar tissue in a client who underwent a mastectomy or lumpectomy is a normal finding and need not be referred.

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

Correct response: Pneumonia Explanation: Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies.

A nurse is examining the breasts of a 75-year-old woman. Which of the following are normal findings in the breasts of an older adult? Select all that apply.

Correct response: Smaller, flatter nipples Nipples that are less erectile on stimulation Pendulous breasts Explanation: The older client often has more pendulous, less firm, and saggy breasts and smaller, flatter nipples that are less erectile on stimulation. Peau d'orange skin, associated with carcinoma, and spontaneous discharge are not normal findings in the breasts of older adults and should be referred for further evaluation.

Benign conditions of the breast include

Correct response: fibrocystic changes Explanation: Cysts (due to BBD) are common lumps that are usually elliptical or round, soft, and mobile. Size may vary, and they often occur in multiple numbers, usually in both breasts, and frequently in the upper outer quadrants.

Lactation after childbirth is stimulated by

Correct response: prolactin secretion Explanation: After childbirth, decreased levels of placental hormones and increased prolactin secretion by the pituitary gland stimulate milk synthesis and cell proliferation.

The nurse auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds?

Correct response: trachea Explanation: Tracheal sounds are very loud and harsh with inspiratory and expiratory sounds equal in length, over the trachea in the neck. Bronchial sounds are louder and higher in pitch and are heard over the manubrium. Bronchovesicular sounds are heard between the scapula. Vesicular sounds are heard over most of the lung fields.

The nurse is preparing to palpate a client's breasts. Which pattern should the nurse follow when completing this assessment?

Correct response: vertical Explanation: The vertical stripping pattern is currently the best validated technique for detecting breast masses. The wedge and circular patterns can also be used to examine the breasts however these patterns are not considered the best validated techniques for detecting breast masses. Quadrant is not an identified pattern for examining the breasts.

Cultural

Diameter of eyes and eyelids Thicker irises in Chinese ethnicity - glaucoma and cataract risk

static confrontation

Stand 2-3 feet from client. Client covers left eye. examiner covers right eye. Client is instructed to look directly at examiner's open eye. Examiner presents 1-4 fingers in each quadrant of vision (inferior, superior, left, right) and has client to identify how many fingers. Then repeat process with other eye. Patient should accurately report number of fingers presented in all quadrants. Static confrontation - for assessment of peripheral vision Cover 1 eye, hold up numbers in each of the 4 quadrants

orthopnea

ability to breathe only in an upright position

anosmia

absence of the sense of smell

halitosis

bad breath

otis media

inflammation of the middle ear

The lymph nodes that are responsible for drainage from the arms are the

lateral lymph nodes

Vestibular function

proprioception and equilibrium Vertigo = inflamed labyrinth causes loss of equilibrium, whirling sensation, room is moving around you Can be due to fluid in ear, infection, allergies Idiopathic

PERRLA

pupils equal, round, reactive to light and accommodation Iris/pupil Pupils: 3-5 mm Equal: Should be same size Round: Not odd shapes Reactive to light: Use pen light, should constrict when exposed to light Direct and Consensual - shine light in one eye, the other pupil should constrict too Accommodation: Look at distance object across the room - pupils should dilate. Then, look at your finger/pen light close up - pupils should constrict.

acute glaucoma

redness around iris, dilated pupil, oval pupil, increased intraocular pressure, emergency, sudden vision clouding and halos (medical emergency!) is blockage of fluid at the base of the eye between the iris and cornea Can result in permanent vision loss if untreated

Thorax consists of

sternum, ribs, costal cartilages, thoracic vertebrae