Health Assessment MC Quiz Q's Exam II

Sensorineural hearing loss

Sensorineural hearing loss can occur from presbycusis (type of hearing loss that occurs with aging) and by ototoxic drugs, which affect hair cells in cochlea

Cranial Nerve X: Vagus

Swallowing and speaking

While percussing over the liver, the nurse finds that the liver span is approximately 7 cm. This would be documented as: a normal finding. enlargement of the liver. displacement due to ascites. displacement as a result of respiratory disease.

a normal finding

Palpation of the adult client's neck reveals nonpalpable lymph nodes. This is A normal finding in adults Reason for referral to an ear, nose, and throat specialist Probably caused by an infection Cause to inspect for further malformations

a normal finding in adults Rationale: Lymph nodes of the head and neck are non-palpable in adults, If an infection were present, the lymph nodes of the surrounding area would be tender and possibly enlarged. The lymph chains of the adult neck should not be able to be palpated and this could be a normal finding in the physical examination.

A bruit of the temporal artery is suspected when the nurse hears? a soft blowing sound a should like hair rustling a vibration a clicking sound

a soft blowing sound

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? "Tilt your head slightly forward." "Keep your head straight and look ahead of you." "Tilt your head back and swallow." "Turn your head to the side against my hand."

tilt your head back and swallow Rationale: To examine the thyroid gland, the nurse should instruct the client to extend her head backward and to swallow. The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland.

cranial nerves

Cranial Nerve I: Olfactory smell Cranial Nerve II: Optic vision Cranial Nerve III: Oculomotor pupil constriction and raise eye lids Cranial Nerve IV: Trochlear downward/inward eye movement Cranial Nerve V: Trigeminal jaw movement sensation of face and neck Cranial Nerve VI: Abducens movement of eyes away from the mid- line of the body Cranial Nerve VII: Facial facial muscle control and sense of taste on lateral 2/3 of tongue Cranial Nerve VIII:Vestibularcochlear hearing/balance Cranial Nerve IX: Glossopharyngeal pharyngeal movement and taste on the posterion 1/3 of the tongue Cranial Nerve X: Vagus swallowing and speaking Cranial Nerve XI: Accessory shoulder movement Cranial Nerve XII: Hypoglossal movement of the tongue and strength of the tongue Mneumonic: oh oh oh to touch and feel very good velvet, ah

Eye Nerves

Cranial Nerve II - Optic Nerve- vision Cranial nerve 3-oculomotor- innervates superior, inferior, and medial rectus and the inferior oblique muscles. Cranial nerve 4- trochlear nerve innervates superior oblique muscles (look at nose) Cranial nerve 6-transducens-innervates lateral rectus muscle, which abducts the eye.

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? Cranial Nerve XII Cranial Nerve X Cranial Nerve VIII Cranial Nerve V

Cranial Nerve XII

Vision

Cranial nerve 2 - ocular nerve

Stick out tongue

Hypoglossal (XII)

The nurse should use coffee to test the function of which cranial nerve?

The olfactory nerve (CN I)

A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? Have the client open his mouth and say, "aah" Ask the client to identify the scent of coffee Use a tongue blade to provoke a gag reflex Have the client smile and raise his eyebrowsa

Have the client open his mouth and say, "aah"

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? Coronary Artery Stents Aneurysm Clip Hearing Aids Automated Internal Defibrillator

Hearing Aids

Facial muscle with Chvostek's

Hypocalcemia. Cranial nerve 7

Assessment of thyroid gland

If enlarged, auscultate thyroid for presence of bruits = indicating hyperplasia of thyroid

The nurse is auscultating a client's abdomen for bowel sounds and no sounds have been detected for at least two minutes. The nurse should Listen for at least three more minutes Document bowel sounds absent and identify the appropriate location Call the physician Document this finding as normal and move on to the next step of the physical assessment

Listen for at least 3 more minutes

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? Sit beside the client during the interview Make sure the device is functioning Make sure lighting in the room is soft Provide a lengthy interview process to allow adequate time to answer questions

Make sure the device is functioning

A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: Obstetric history, because it includes the most important information. Sexual history, because discussing it first will build rapport. Menstrual history, because it is generally nonthreatening. Urinary system history, because problems may develop in this area as well.

Menstrual history, because it is generally nonthreatening.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: diarrhea. peritonitis. laxative use. gastroenteritis.

Peritonitis

Lymph nodes

Preauricular Postauricular Occipital Tonsillar (Jugulodigastric) Submandibular Submental Anterior cervical Posterior Cervical Deep cervical Supraclavicular Infraclavicular

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? Initiate seizure precautions. Ensure the client receives a soft diet. Provide an obstacle-free path for ambulation. Instruct the client to use lukewarm water when showering.

Provide an obstacle-free path for ambulation.

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have Finding the bathroom in the dark Driving at night Seeing numbers on highway signs Reading the newspaper

Reading the newspaper

Tympanic Membrane and its location

The TM should be intact, symmetrical, shiny and translucent with a pearl gray color, flat, slightly pulled in at center Valsalva movement will flutter TM

The nurse hears dullness while percussing over the left lower quadrant. What would be the most appropriate question to ask the client? "When was your last bowel movement?" "Have you ever had splenomegaly?" "Do you have pain after eating?" "What is your normal diet?"

"When was your last bowel movement?"

Facial Cranial nerves

Cranial nerve 5- Trigeminal nerve- Palpation Motor: Jaw movement Sensory: carries afferent sensation to brain (cotton ball test) Cranial Nerve 7- Facial Nerve-inspection Taste - salt/sweet Facial expressions Blinking

Abduct eye

Cranial nerve 6- transducens

Taste(salt/sweet), facial expressions, blinking

Cranial nerve 7 Facial nerve.

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment Gingivitis Dry, brittle hair Edema Spoon-shaped nails Poor wound healing

- dry, brittle hair - edema - poor wound healing

Signs and symptoms of Otitis Media

-fever, pain; infant may pull at ear -enlarged lymph nodes -discharge from ear (if drum is ruptured) -upper respiratory symptoms -vomiting, diarrhea Obstruction of Eustachian tube or passage of nasopharyngeal secretions into the middle ear that occurs mostly in children.This is determined by frequent outpatient visits, hearing loss, dry cerumen present which are gray flaky in the ear canal and wet cerumen which are honey brown to dark brown and moist.

The nurse is percussing over the client's bladder and notes a dull tone. The nurse understands this to represent A full bladder An empty bladder Percussion over one of the kidneys Air trapped in the intestines

A full bladder

Anisocoria Miosis Mydriasis

Anisocoria: difference in pupil size Miosis: excessive constriction of the pupil Mydriasis: dilation of pupil of the eye

Ankyloglossia

Ankyloglossia: tongue tied the frenulum is too short and tight to the tongue and the tongue cannot move freely.

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? Air conduction is less than bone conduction in the left ear. Air conduction is greater than bone conduction in the left ear. Sound is lateralizing to the right ear Sound is lateralizing to the left ear.

Air conduction is less than bone conduction in the left ear.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? Speak directly into the client's impaired ear Exaggerate lip movements Speak loudly Face the client when speaking

Face the client when speaking

A woman has just been diagnosed with HPV or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _______ cancer. Ovarian Endometrial Uterine Cervical

Cervical

A nurse is preparing to assess the function of the client's Olfactory nerve (cranial nerve I). Which of the following items should the nurse gather for the test? Sugar Coffee Cotton Wisps Snellen Chart

Coffee

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? Confrontation test Symmetry of palpebral fissures Corneal light reflex Accommodation test

Corneal light reflex

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? Sugar Coffee Cotton Wisps Snellen Chart

Cotton Wisps Rationale: The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth.

Look around

Cranial nerve 3 Occulomotor

Look at nose

Cranial nerve 4 trochlear nerve innervates superior oblique muscles.

Jaw movement, and superficial sensation

Cranial nerve 5 Trigeminal nerve

The nurse palpates the abdominal aorta of an adult client and find that it measures approximately 6 cm in diameter. The next step for the nurse to take is To continue to apply deep palpation inferiorly to assess accurate measurement To palpate lightly to just under the xiphoid process Discontinue palpation and document findings Auscultate for bruits

Discontinue palpation and document findings Rationale: The aorta is palpable in the upper abdomen to the left of midline below the xiphoid process and the average adult aorta is 3 cm wide. A widened aorta may indicate aneurysm and should not be palpated to avoid rupture.

The nurse is examining an adult male and notes thick and curly hair over the pubis area, a pear shaped scrotum, and slightly darkened skin on the penis. The nurse would correctly choose which of the following actions? Document the findings as normal. Notify the physician of the findings. Ask the client about childhood illnesses. Ask the client about risk taking sexual practices.

Document the findings as normal.

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? Obtain an audiology referral Document this as an expected finding Irrigate the ear with warm water Document mild inflammation

Document this as an expected finding

A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? Base of the fingers Palmar Surface Fingertips Dorsal surface

Dorsal Surface

DYSPHASIA VS DYSPHAGIA

Dyspha*s*ia = inability to speak (*S*PEECH) Dyspha*g*ia = inability to swallow (*G*ULP)

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? Annual Papanicolaou (Pap) testing Mammogram every 2 years Eye examination every 2 years Annual colonoscopy

Eye examination every 2 years

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

Firm pressure

A nurse is teaching a client who wants to stop smoking by using nicotine gum. The nurse should inform the client that which of the following adverse effects can occur from using nicotine gum? Itching Throat Irritation Hiccups Teary Eyes

Throat irritation

Cranial Nerve XI: Accessory

Traps, head movement

Rinne Test findings for conductive hearing loss.

Tuning fork AC Conductive hearing loss Bone conduction = BC AC should be greater than BC AC = BC or AC < BC

Tongue glands

WHARTONS: Sublingual gland smallest, lies withinfloor of mouth under tongue and has many small openings along sublingual fold under tongue (S)TENSONS: opening of parotid salivary gland and is an expected finding (S)=Spit

Conductive hearing loss

can occur because of impacted cerumen, foreign bodies, a perforated TM, pus or serum in the middle ear and otosclerosis

strabismus

cross-eyed Corneal eye reflex

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased Calcium Decreased Potassium Increased Potassium Increased Calcium

decreased Calcium Rationale: Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is <8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

aphasia

impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).

Presbyopia (farsightedness)

impairment of vision as a result of old age Can't read newspaper

Assessment of GI

inspect auscultate percuss palpate