Lesson 4

The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client?

"You have a conductive hearing loss."

When visual acuity is tested using the Snellen eye chart, which result suggests better distance vision?

30/20

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

Ask the client to remove the glasses before testing.

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

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

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

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

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

CN 7

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

Compressing the arteries bilaterally

When conducting the Weber test a client reports hearing the sound better in the right ear. What should this finding indicate to the nurse?

Conductive hearing loss in the right ear

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?

Consensual response

During a health history, a 42-year-old male client reveals that he is seeing spots before his eyes. The nurse interprets this finding as the result of which of the following?

Normal findings for client's age

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

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

Which of the following tests use a tuning fork between two positions to assess hearing?

Rinne

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

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

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

acute bacterial sinusitis

Which action by the nurse is appropriate to provide a clear view of the uvula for observation?

ask client to say aah

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?

history of allergies

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.

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

Which action by the nurse indicates the appropriate use of ophthalmoscope?

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

Which action by the nurse is consistent with Weber's test?

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

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

Weber

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

Whisper test

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

percussion