Health exam 2 cp questions

What is the highest score a patient can achieve in the Glasgow Coma Scale (GCS)?

15

Which cranial nerves "make the eyes do tricks?"

3, 4, 6 (oculomotor, trochlear, abducens)

The nurse is concerned that a client is at risk for developing Alzheimer disease. Which assessment finding caused the nurse to have this concern? Select all that apply. A. Smokes cigarettes B. Treatment for hypertension C. Bowls once a week D. Age 70 E. Gained 10 kg over the last year

A, B, D

Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply. A. Regularly exercising B. Maintaining a healthy weight C. Quitting smoking D. Eating a high-sodium diet E. Following a sedentary lifestyle

A,B,C Explanation: Clients with obesity, in particular abdominal obesity, are at increased risk for ischemic stroke. Nurses should teach clients to reduce calorie intake and to gradually increase activity. Smokers are also at increased risk for stroke. Nurses should counsel clients at every visit about willingness to quit smoking.

Which possible causes should you consider when assessing a patient with an acute change in mental status? (Select all that apply.) A. Psychiatric disorders B. Adverse medication effects C. Electrolyte imbalances D. Drugs or alcohol E. Delirium

A,B,C,D,E Explanation: An acute change in mental status can be caused by many different factors. This underlies the need to assess each patient comprehensively and to avoid making assumptions about etiology.

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client? A. Instruct the client to flex and extend the right elbow B. Ask the client to close the eyes C. Instruct the client to state the current date and place D. Instruct the client to smile

A. Explanation: Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment.

Sensations of temperature, pain, and crude and light touch are carried by way of the A. spinothalamic tract B. corticospinal tract C. extrapyramidal tract D. posterior tract.

A. Explanation: Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract.

A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first? A. "Walk across the room and back." B. "Hop on one spot." C. "Walk on your toes then on your heels." D. "Walk heel to toe."

A. "Walk across the room and back." Explanation: It is important to ask the client to walk across the room and walk back first because this will reveal deficits in the gait. This, in turn, will allow the nurse to focus the assessment. Asking the client to walk across the room and then back assists the nurse in observing posture, balance, swinging of the arms, and movements of the legs. Asking the client to walk heel to toe is called "tandem walking." It would be appropriate to instruct the client to do this to determine if there is ataxia that was not previously obvious. Asking the client to walk on the toes then on the heels assists the nurse in assessing for plantar flexion of the ankles as well as for balance. The nurse should instruct the client to do this if problems with balance are noted initially. Asking the client to hop in place provides information about the client's position sense and cerebellar function. If the nurse is not yet aware whether the client is at risk for falls, this assessment should be left until the quality of gait has been assessed

The nurse assesses the frontal sinus where? A. Above the eyes B. Below the eyes C. Above jaw D. Below jaw

A. Above the eyes

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: A. Cancers often occur. B. Lesions from loose dentures are found. C. Sloughing of papillae begins. D. Early jaundice can be detected.

A. Cancers often occur.

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? A. Dysphagia B. Right ptosis C. Facial weakness D. Weak gait

A. Dysphagia

The nurse is caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client has a 25-year history of smoking. The nurse performs an assessment and asks the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? A. Hoarseness B. Dyspnea C. Dysphagia D. Alopecia

A. Hoarseness

During an oral assessment, the nurse identifies that client has white patches in their mouth. How would this be documented in the medical record? A. Leukoplakia B. Fordyce granules C. Petechiae D. Gingivitis

A. Leukoplakia

The cerebrum is divided into right and left hemispheres, which are joined together by the.. A. corpus callosum B. pons C. diencephalon D. medulla oblongata

A. corpus callosum Explanation: The cerebrum is divided into the right and left cerebral hemispheres, which are joined by the corpus callosum—a bundle of nerve fibers responsible for communication between the hemispheres.

Which cranial nerve is responsible for the ability to see? A. CN I B. CN II C. CN III D. CN IV

B

Which of the following are cues that a person may have dementia? Select all that apply. A. Finding the right words easily B. Looking to a family member to answer questions directed to the client C. Repeatedly failing to follow instructions D. Disorientation E. Serving as a "good historian"

B, C, D

Delirium can be caused by which factors? (Select all that apply.) A. Cerebrovascular accident (CVA) B. Vitamin deficiencies C. Alzheimer disease D. Metabolic disturbances E. Fluid imbalances

B, D, E Explanation: Delirium is a treatable change in mental status that can result from many varied factors. These include metabolic problems, fluid imbalances, and vitamin deficiencies. The cognitive changes that result from a CVA are not usually considered to be easily reversible, and are consequently not characterized as delirium. Alzheimer disease causes dementia.

A client has an injury that affects the posterior sensory nerve columns of the spinal cord. Which of the following will the nurse most likely find during the examination of the sensory system? Select all that apply. A. Loss of depth perception B. Changes in the perception of vibration C. Change in pain perception D. Alteration in temperature sense E. Alteration in the perception of position

B, E Explanation: Fibers conducting the sensations of position, vibration, and fine touch pass directly into the posterior columns of the spinal cord and travel to the medulla. With this client's injury, the nurse will most likely find an alteration in the perceptions of position and vibration. Fibers conducting pain and temperature sensations pass into the posterior horn of the spinal cord. An injury to the posterior sensory nerve columns of the spinal cord will not cause a loss of depth perception.

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? A. tuning fork B. tongue depressor C. speculum D. gloves E. penlight

B,D,E

The nurse enters a client's room to administer a prescribed anticoagulant for atrial fibrillation. The client exhibits new onset facial drooping and slurred speech. What is the nurse's priority action? A. Assess the client's vital signs and cranial nerves. B. Ask the client to raise both arms in front of the client's body. C. Assess the client's bleeding time before medication administration. D. Administer the PO anticoagulant immediately.

B. Explanation: Atrial fibrillation increases risk for stroke because quivering atria can lead blood to stagnate and then form small clots. A clot that breaks off can circulate to the brain and block the artery, causing an embolic stroke. In sickle cell disease, blood cells tend to be stickier, causing clots to form more easily in narrowed arteries. This client's symptoms are consistent with a possible stroke. The nurse's priority is to perform a brief focused assessment and notify the health care provider right away. Administering the medication and checking the labs are not priorities of care during the acute phase of a stroke. Vital signs should be assessed right away, but it is not necessary to test cranial nerves initially.

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what? A. Loss of visual fields on the left B.Drooping of the left eye C. Drooping of the left side of the mouth D. Swelling of the optic nerve

B. Explanation: Ptosis is drooping of the eye lid. Swelling of the optic nerve is papilledema. A loss visual fields may be associated with retinal detachment or damage.

An older client is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this client? A. "What are the parts of a watch?" B. "What is today's date?" C. "What do you think is wrong?" D. "Do you think that life is not worth living?"

B. "What is today's date?" Explanation: The mini-mental state examination is a brief test used to screen for cognitive dysfunction or dementia over time. One question in this examination addresses orientation to time or "what is the date." The question "what are the parts of a watch" is part of an aphasia assessment. The question "do you think that life is not worth living" is used to assess mood. The question "what do you think is wrong" is used to assess insight.

What should the nurse assess to test the function of the occipital lobe? A. Tactile sensation B. Ability to read C. Impulses from the ear D. Communication

B. Ability to read Explanation: To assess the function of the occipital lobe, the nurse should test the ability to read. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. Assessment of the frontal lobe is done by testing the client's communication.

The nurse is performing the Romberg test. Which of the following indicate a normal finding? A.Client sways when eyes are closed B.Client stands erect with minimal swaying C. Client prevents themself from falling D. Client maintains balance when walking

B. Client stands erect with minimal swaying Explanation: The Romberg test is negative is the client stand erect with minimal swaying with eyes both opened and closed. Balance when walking is not part of the Romberg test.

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? A. Vital signs B. Coordination C. Cardiac function D. Neurologic system

B. Coordination Explanation: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination. The other options listed are distracters.

The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score? A. Ability to recall recent and remote memories, and to use abstract reasoning. B. Eye opening, and appropriateness of verbal and motor responses. C. Naming of objects, recall of three words, and ability to redraw a design. D. Assessment of the 12 cranial nerves.

B. Eye opening, and appropriateness of verbal and motor responses.

A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse? A. Parkinson's disease B. depression C. mania D. obsessive-compulsive disorder

B. depression

A nurse is assessing the mouth of a client and finds that they have a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin? A. C B. D C. B12 D. K

C

The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client? A. Weak hand grasps B. Unsteady gait C. Swaying D. Poor brachial reflex

C. Explanation: A positive Romberg test is when the client sways and moves the feet apart to prevent falling. The Romberg test is not used to assess gait, hand grasps, or the brachial reflex.

Which tests are appropriate for a nurse to perform to test cranial nerve VIII? A. Smile, frown, show teeth, and puff out cheeks B. Gag reflex, rise of the uvula, and ability to swallow C. Whisper, Rinne, and Weber tests D. Clench the teeth, light touch, and sharp/dull discrimination

C. Explanation: Cranial nerve VIll is the acoustic/vestibulocochlear nerve, which is associated with the client's ability to hear. The nurse should perform the whisper test and, using the tuning fork, the Rinne and Weber tests. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharyngeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out the cheeks assesses the function of cranial nerve VII (facial). Clenching the teeth, identifying light touch, and discriminating between sharp and dull stimuli are assessments of cranial nerve V (trigeminal).

What task should a nurse ask a client to perform to assess the function of cranial nerve XI? A. walk in heel-to-toe fashion B. move tongue side to side C. shrug shoulders against resistance D. swallow water

C. Explanation: The function of cranial nerve XI can be assessed by asking the client to shrug their shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.

A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior? A. cranial nerves B. sympathetic C. parasympathetic D. central

C. Explanation: The parasympathetic nervous system conserves energy and resources during times of rest and relaxation. The central nervous system consists of the brain and spinal cord. The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal. The cranial nerves emerge from within the cranial vault through skull foramina and canals to structures in the head and neck.

The nurse is assessing a client who appears to have a swollen thyroid gland (goiter). Which of the following is a priority question the nurse should ask the client? A. "What type of table salt do you use?" B. "Has your weight changed over the last few months?" C. "Do you have any difficulty swallowing?" D. "Do you have difficulty sleeping at night?"

C. "Do you have any difficulty swallowing?"

When testing the biceps reflex, what type of response should the nurse expect if normal? A. Forearm adducts and wrist rotates B. Elbow extends and muscle contracts C. Elbow flexes and muscle contracts D. Forearm flexes and supinates

C. Elbow flexes and muscle contracts Explanation: To elicit the biceps reflex, the nurse should ask the client to partially bend the arm at elbow with palm up. The nurse places the thumb over the biceps and strikes the thumb with the reflex hammer. The normal finding with this reflex is the elbow flexes and contraction of the biceps muscle occurs. When assessing the brachioradialis reflex, the normal finding is flexion and supination of the forearm. The other two are not findings elicited with upper extremity reflexes.

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults? A. Brown spots on the chewing surface of teeth B. Bifid uvula C. Receding and ischemic gums D. Enlarged palatine tonsils

C. Receding and ischemic gums

A nurse is preparing to offer a community education session on anxiety. On which part of the nervous system should the nurse focus during the discussion? A. somatic nervous system B. motor pathways C. sympathetic nervous system D. sensory pathways

C. sympathetic nervous system Explanation: The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal, such as with the experience of anxiety; this is the part of the nervous system on which the nurse should focus during the discussion. Motor pathways are complex avenues extending from upper motor neurons through long, white-matter tracts, to synapses with lower motor neurons, and into the periphery (outward regions) through peripheral nerve structures. Sensory pathways refers to a complex system of sensory receptors relaying impulses from skin, mucous membranes, muscles, tendons, and viscera that travel through peripheral projections into the posterior root ganglia, where a second projection of the ganglia directs impulses centrally into the spinal cord. The somatic nervous system regulates muscle movements and response to sensations of touch and pain.

Brain tumors and other malignancies of the neurologic system are a common cause of traumatic brain injury (TBI). TRUE FALSE

False Explanation: TBI results from an acute event such as a blow to the head or a penetrating wound to the head.

A client visits the clinic and tells the nurse that they have not been feeling very well. The nurse observes that the client's speech is slow, the client has a disheveled appearance, and they maintain poor eye contact with the nurse. The nurse should further assess the client for A. schizophrenia. B. hallucinations. C. delirium. D. depression.

D.

A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis? A. Closure of the affected eye from swelling B. Muscle spasm of the lower face on the affected side C. Inability to detect sharp and dull stimuli D. Inability to wrinkle the forehead

D. Explanation: Inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face on the affected side, is seen with Bell's palsy. Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma. Paralysis, not muscle spasm, occurs with Bell's palsy.

Which Glasgow Coma Score indicates the client is in a deep coma? A. 15 B. 8 C. 14 D. 3

D. 3 Explaination: A Glasgow Coma Scale score indicates the client is in a deep coma. All other scores indicate some impairment with a score of 15 being no impairment.

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested? A. Concentration. B. judgment. C. Memory to learn new information. D. Abstract reasoning

D. Abstract reasoning

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom? A. Oropharyngitis B. Eye infection C. Acute otitis media D. Acute bacterial rhinosinusitis

D. Acute bacterial rhinosinusitis

The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client? A. Use a verbal 0-10 rating scale B. Clients assigned this low score are pain free C. Utilize the FACES scale D. Assess for nonverbal signs

D. Assess for nonverbal signs Explanation: The GCS is a tool for assessing a client's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response: Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response: Obeys command 6 Localizes pain 5 Withdraws 4 Flexion 3 Extension 2 None 1 Total 3-15. A score of three indicates deep coma; therefore, the client is unable to verbalize pain level on numerical scale or FACES scale. A client in a coma can still experience pain.

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address? A. Mental status exam B. Remote memory C. Sensation D. Balance

D. Balance Explanation: Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.

Which clients are most at risk for depressive symptoms? (Select all that apply.) A. Chronically Ill clients B. Married clients C. Females D. Divorced clients E. Males

D. Divorced clients A. Chronically Ill clients C. Females

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? A. Right ptosis B. Facial weakness C. Weak gait D. Dysphagia

D. Dysphagia

During a physical exam, Molly, the nurse, notes a very tender, reddened, hot, and swollen bulge on the metatarsophalangeal (MTP) joint of her patient's great toe. Which of the following conditions should Molly suspect? A. Bunion B. Rheumatoid arthritis C. Plantar fasciitis D. Gouty arthritis

D. Gouty arthritis Explaination: Actually, Molly should suspect that her patient has gouty arthritis. Gout is a form of inflammatory arthritis that causes sudden, severe pain, swelling and tenderness; most often found in the large joint of the great toe.

What is the best way to assess cranial nerve XI, the accessory nerve? A. Have the patient move their tongue B. Have the patient swallow C. Test the patients gag reflex D. Have the patient move their shoulders up and down

D. Have the patient move their shoulders up and down. Explanation : The best way to assess the accessory nerve is to have the patient move their shoulders up and down. Moving the tongue tests the hypoglossal nerve, and swallowing and gag reflex test the glossopharyngeal nerve.

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control? A. Cerebral cortex B. Medulla C. Brain stem D. Hypothalamus

D. Hypothalamus Explanation: The hypothalamus controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions. It maintains overall autonomic control. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness.

A client comes to the clinic reporting pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, and forehead for the past 12 weeks. Based on these findings, which of the following disorders is the client most likely experiencing? A. epistaxis B. deviated septum C. chronic sinusitis D. acute rhinitis

D. acute rhinitis

A client comes to the clinic reporting pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, and forehead for the past 12 weeks. Based on these findings, which of the following disorders is the client most likely experiencing? A. epistaxis B. acute rhinitis C. deviated septum D. chronic sinusitis

D. chronic sinusitis

A client reports having had difficulty breathing through their right nostril for years. The client denies any other symptoms except for unrestful sleep. The nurse suspects that the client may have which of the following conditions? A. acute sinusitis B. rhinorrhea C. congestion D. deviated septum

D. deviated septum

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test? A. supinator B. ankle C. triceps D. patellar

D. patellar

The roof of the oral cavity of the mouth is formed by the anterior hard palate and the A. muscles. B. teeth. C. gums. D. soft palate.

D. soft palate

What is the Glasgow Coma Scale (GCS) used to assess?

Level of consciousness

Which cranial nerve affects heart rate and digestion?

Vagus

Movement towards the midline

adduction

The client has been admitted for depression. What should the nurse include in the admission mental status assessment? Select all that apply. A. Fluid intake B. A recent loss C. Headaches D. History of a stroke E. New physiological impairment

b,e Explanation: The mental status assessment should include questions related to loss; and change in physiological status, including history of a stroke. Headache and fluid intake would not be part of the mental status assessment but may play a role in the client's mental status.

When should the mental status exam be performed?

beginning

Part of the brain that maintains equilibrium and muscle tone

cerebellum

Protective substance found in the external auditory canal

cerumen

Davio, a 54-year-old male, reports to the clinic for a deep wound on his finger. He weighs 300 pounds, has high blood pressure, and leads a sedentary lifestyle. He appears well-groomed and has normal speech and movements. He is proud of recently completing a 6-week alcohol treatment program and denies current use of any alcohol or drugs. The nurse notices breath odor of alcohol. Which factors could be the cause of this odor? Select all that apply. diabetic ketoacidosis alcohol withdrawal pain medication diet

diabetic ketoacidosis, alcohol withdrawal Explanation: Alcohol withdrawal and diabetes can produce alcohol or acetone smelling odors. Diet and over-the-counter pain medication are not normally associated with alcohol breath smell.

Risk factor for CVA

ethnicity

Gait with high step and slapping of the foot

footdrop

Least common type CVA

hemorrhagic

One potential cause of delirium

infection

Common musculoskeletal finding in older adults

kyphosis

Slowed or sluggish speech, metal processes, or motor activity

lethargy

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment? A. None B. Minimal C. Coma D. Deep coma

none

Cause of localized joint pain

osteoarthritis

Common ear infection in children

otitis media/ swimmers ear

Age related hearing loss

presbycusis

Immunocompromised client's my have this abnormal tongue finding

thrush

This can happen from ototoxic medications, HTN, or exposure to loud environmental noise

tinnitus

Abnormal finding on the external ear caused by uric acid build up

tophi

Rheumatoid arthritis causes finger deviation to the_____ side

ulnar

Dementia that results from a stroke

vascular

. ______ women are most at risk for osteoporosis

white