MODULE 7 HEENT, Neurological Assessment, Cognitive and Sensory Deficits

The nurse is assessing the neurologic system of an adult client. To test the client's use of memory to learn new information, the nurse should ask the client "What did you have for breakfast?" "How old were you when you began working?" "Can you repeat rose, hose, nose, clothes?" "Can you repeat brown, chair, textbook, tomato?"

"Can you repeat brown, chair, textbook, tomato?" Explanation: Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders.

Which assessment notation describes a client's level of consciousness? "Client was inattentive to the questions being asked." "Client answered questions both logically and coherently." "Client was alert and cooperative during the assessment." "Client demonstrated difficulty with recalling events occurring this morning."

"Client was alert and cooperative during the assessment." Explanation: Alertness or state of awareness of the environment is associated with level of consciousness. Inattentiveness is related to attention or ability to focus on tasks. Thought processes are evaluated through logical and coherent responses. Memory involves the ability to recall facts.

An older adult client comes to the health center reporting difficulty sleeping. Which statement by the client would the nurse need to address? "I try not to be too active once I've eaten dinner." "I find myself napping on and off throughout the day." "I go to bed around 10:30 pm every night." "I don't drink coffee or alcohol."

"I find myself napping on and off throughout the day." Explanation: The client's statement about napping throughout the day will need to be addressed by the nurse because this can interfere with the client's ability to sleep at night. Avoiding activity after dinner, having a routine bedtime, and avoiding caffeine and alcohol are healthy sleep habits.

measures to promote sleep with an older adult who is experiencing frequent awakenings at night and then awakening early in the morning. The nurse determines that the education was successful when the client states: "I should do some mild exercises about 2 hours before bedtime." "I need to try and go to bed and get up at the same time each night." "I should continue to take my sleep medication for as long as I need to." "I should avoid coffee, but tea is okay to drink before bed."

"I need to try and go to bed and get up at the same time each night." Explanation: Sleep measures include maintaining a routine, going to bed and getting up at the same time each night, avoiding exercise 3 to 4 hours before bed, using prescribed sleep medications only for the short-term (7 to 14 days), and avoiding alcohol, nicotine, and caffeine (which tea contains).

The nurse is assessing the client's ability to make sound judgments. Which question would be best for the nurse to ask? "Do you usually eat breakfast?" "How many dimes are in one dollar?" "If you lost your job, how would you plan to pay your rent or mortgage?" "Can you keep track of your finances on an ongoing basis?"

"If you lost your job, how would you plan to pay your rent or mortgage?" Explanation: The nurse can often assess judgment by asking questions about family situations, jobs, money management, and interpersonal conflicts. An open-ended question that asks the client to make a plan for a hypothetical situation, such as a loss of income, will elicit more information about judgment than asking a yes/no question. The questions about whether the client eats breakfast or can manage money are yes/no questions and will reveal little information about the client's judgment. "How many dimes are in one dollar?" is a knowledge question that does not elicit information about judgment.

A nurse is teaching an elderly client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following? "Dementia is an acute process and develops suddenly." "Sundowning is a common problem of dementia." "Delirium progressively affects cognitive function and is a chronic process." "Alzheimer's disease (AD) is a reversible neurologic illness."

"Sundowning is a common problem of dementia." Explanation: A common problem in patients with dementia is sundowning syndrome, in which an older adult habitually becomes confused, restless, and agitated after dark. Dementia is chronic and usually develops gradually. AD is the most common degenerative illness and is irreversible. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment.

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? "Walk across the room and back." "Walk heel to toe." "Walk on your toes then on your heels." "Hop on one spot."

"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.

Which question is appropriate for a nurse to ask a client to assess the client's recent memory? "When is your birthday?" "What did you eat for breakfast today?" "How are an orange and an apple different?" "Why are you at the health care clinic today?"

"What did you eat for breakfast today?" Explanation: When assessing a client's recent, or short-term, memory ask the client about things and events that are happening currently. Asking the client what he or she ate for breakfast is testing recent memory. Asking the client their birth date tests remote memory. Asking how an orange and an apple are different tests a client's ability for abstract reasoning. Asking the client the reason for today's health clinic visit is used to identify the client's chief complaint

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? Normal, air-filled sinuses A large amount of exudate in the sinuses Obstruction of the nostril by a foreign object A perforated septum

A large amount of exudate in the sinuses Explanation: Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses. Normal, air-filled sinuses would not demonstrate crepitus. Obstruction of the nostril by a foreign object would prevent sniffing or blowing air through the nostrils, but would not produce crepitus. A perforated septum would also not produce crepitus.

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

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.

Where is the temporal artery palpated? Above the cheek bone near the scalp line Just left of midline at the base of the neck Between the mandibular joint and the base of the ear Just left or right of the spine at the base of the skull

Above the cheek bone near the scalp line Explanation: The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.

The nurse assesses the frontal sinus where? Above the eyes Below the eyes Above jaw Below jaw

Above the eyes Explanation: The frontal sinuses are located above the eyes. The maxillary sinuses are located above the jaw.

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition? Metastatic disease Chronic infection Acute infection Cushing's disease

Acute infection Explanation: The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease.

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? Always use seat belts. Wear nonslip shoes in the house. Avoid risky activities such as snowboarding Use of guns should be supervised by an adult

Always use seat belts. Explanation: The third leading cause of traumatic brain injury is motor vehicle crashes. When instructing a group of adolescents on ways to prevent traumatic brain injuries, the most important thing for the nurse to include would be to always use seat belts. Wearing nonslip shoes in the house is a more appropriate teaching point for adults over 65 years of age. Instead of teaching adolescents to avoid risky activities such as snowboarding; they should be reminded to always wear a helmet. Adolescents should not be encouraged to use firearms. Instead, they should ensure that the responsible adult has stored the bullets and firearm in separate locations.

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following? Arcus senilis Presbyopia Ectropion Myopia

Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what? Arthritic changes of the cervical spine Bacterial thyroiditis Cranial damage Muscle tension

Arthritic changes of the cervical spine Explanation: Arthritic changes in cervical spine may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles

Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead

Asks the client to fix the gaze upon an object and look straight ahead Explanation: After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.

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? Use a verbal 0-10 rating scale. Utilize the FACES scale. Assess for nonverbal signs. Clients assigned this low score are pain free.

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 client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? Work with medical team to evaluate possible surgery. Discuss pharmacologic interventions. Educate the client regarding cervical spine pain. Assess the client regarding characteristics of the pain.

Assess the client regarding characteristics of the pain. Explanation: The first step would be for the nurse to assess characteristics of the pain. Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. While education is an appropriate intervention, it would not be addressed initially but rather after pain management interventions were implemented.

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? Client did not wear his glasses for this test and therefore it is not accurate. When 50 feet from the chart, the client can see better than a person standing at 20 feet. Client can read the 20/50 line correctly and two other letters on the line above. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. Explanation: The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish.

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 C D K

B12 Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B12 or niacin.

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition? Trigeminal neuralgia Preauricular adenitis Temporomandibular joint syndrome Bell's palsy

Bell's palsy Explanation: One-sided facial drooping is present in Bell's palsy due to inflammation of the facial nerve. Trigeminal neuralgia causes shooting, piercing facial pains that occur over the divisions of the fifth cranial nerve. Preauricular adenitis is characterized by tenderness and swelling of the lymph nodes in front of the ears. Temporomandibular joint syndrome causes pain or crepitation with jaw movement.

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? Rush Gurgle Murmur Bruit

Bruit Explanation: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. A murmur is assessed during a cardiac assessment.

What lines the cheeks? Lingual mucosa Alveolar mucosa Buccal mucosa Labial mucosa

Buccal mucosa Explanation: The buccal mucosa lines the cheeks.

The nurse is assessing a middle-aged adult age 48 years in the clinic. The nurse recalls the changes that occur in middle age as they complete the physical and cognitive examination. Changes that occur include what? Cardiac output decreases. Loss of fatty tissue Low-pitched sounds are more difficult. Visual acuity changes with myopia.

Cardiac output decreases. Explanation: Middle age changes include the following: redistribution of fatty tissue around the middle and abdomen; drier skin; wrinkles develop; hair grays and men may experience baldness; cardiac output decreases; near-vision diminishes; presbyopia; hearing diminishes, especially high-pitched sounds; hormone levels decrease; calcium loss from bone occurs; decrease in muscle strength.

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem? Cerebellum Temporal lobe Cranial nerves Deep tendon reflexes

Cerebellum Explanation: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. The temporal lobe is part of the cerebrum and helps with receiving and interpreting impulses from the ear. The cranial nerves evolve from the brain or brain stem and transmit motor or sensory messages. Deep tendon reflexes are part of the sensory pathway of the spinal cord, which relay an impulse to the motor nerve and then to the muscles.

The nurse identifies this as trapping debris and propelling it toward the nasopharynx. Cilia Turbinates Columella Lacrimal duct

Cilia Explanation: Cilia capture and propel debris toward the nasopharynx. Turbinates are bony lobes that project from the lateral walls of the nasal cavity. The lacrimal duct receives drainage. The columella divides the nostrils.

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

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.

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what? Conjunctiva Limbus Lacrimal apparatus Eyelid

Conjunctiva Explanation: The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae). The border between the cornea and the sclera is the limbus. The lacrimal apparatus protects and lubricates the cornea and the conjunctiva by producing and draining tears. The eyelid is a loose fold of skin that covers and protects the eye.

A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following? Retina Sclera Cornea Conjunctiva

Conjunctiva Explanation: The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends them to the brain. The sclera is a dense, protective, white covering that physically supports the internal structures of the eye. The transparent cornea permits the entrance of light, which passes through the lens to the retina.

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

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.

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? Cranial nerve I (olfactory) Cranial nerve V (trigeminal) Cranial nerve VII (facial) Cranial nerve IX (glossopharyngeal)

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 is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client? Reddish Cyanotic Pallor Swelling

Cyanotic Explanation: Cyanotic lips are seen in cases of cold or hypoxia. The finding of reddish lips supports the diagnosis of carbon monoxide poisoning. Pallor around the lips is a finding in clients with anemia and shock. Swelling of the lips is common in local or systemic allergic reaction.

A 78-year-old woman is status post right hip fracture after a fall. She has stopped going to her church over the past few months. She has also asked her neighbor to help her and do her gardening, an activity she previously loved. The client tells the nurse "I just don't enjoy gardening like I used to. I am always worried about falling." What would most concern the nurse regarding the client? Depression Generalized anxiety disorder Realistic caution Bipolar disorder

Depression Explanation: The nurse should assess the client and determine if depression is occurring first. Depression can be treated and the client's condition improved. If depression is not the issue, then the nurse could further assess and determine if there is another issue which should be addressed.

A nurse is preparing to medicate an older adult client with an opioid analgesic. Which information will the nurse obtain first to decide about administering the medication? Observing client behavior to determine if coincides with report of pain Taking the clients vital signs to determine if indicative of pain Determining if the client is able to communicate pain verbally or nonverbally Obtaining family feedback about client's pain level

Determining if the client is able to communicate pain verbally or nonverbally Explanation: The nurse should ascertain the level and intensity of the client's pain. The family is not able to give adequate information about the client's pain. Taking the client's vital signs can be of value as a baseline. A client may share indication of pain other than verbally, such as a grimace or moaning. Each client may exhibit different behaviors when in pain. This is not a reliable indicator as to a client's pain level.

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

Dysphagia Explanation: Dysphagia can lead to aspiration and is the priority concern to maintain a patent airway. A weak gait can lead to falls but is not priority over airway. Right ptosis, or eyelid drooping, and facial weakness can inhibit certain facial movements but this is not a priority concern over airway.

Why is it important to ask the client regarding discharge or drainage from the eyes? Discharge is associated with inflammation or infection Discharge is associated with glaucoma Discharge is associated with presbyopia Discharge is associated with a detached retina

Discharge is associated with inflammation or infection Explanation: Discharge is associated with inflammation or infection. Glaucoma is a disease of the optic nerve that involves loss of retinal ganglion cells. With aging, the ability of the lens to accommodate decreases. Near vision is subsequently impaired, and thus older adults need reading glasses. This is presbyopia. Discharge is not an indication of a detached retina.

Which clients are most at risk for depressive symptoms? (Select all that apply.) Married clients Divorced clients Females Males Chronically ill clients

Divorced clients Females Chronically ill clients Explanation: Watch carefully for depressive symptoms, especially in clients who are young, female, single, divorced or separated, seriously or chronically ill, or bereaved. Those with a prior history or family history of depression are also at risk.

The nurse understands that when caring for the older adult it is important to assist in maintaining independence and self-esteem. Assisting the client to adjust to a walker or wheelchair is an example of supporting which of Erikson's developmental tasks of the older adult? Adaptation to age and preservation of self Ego integrity and coping with reality of limitations Functional adaptation and self-awareness Prevention of injury and safety in navigation

Ego integrity and coping with reality of limitations Explanation: Age does affect the older adult due to many different physiological changes, as evidenced by a decrease of cardiac output, peripheral circulation, oxygenation of blood, decreased ability to control temperature, and a slower heart rate. Ego integrity is the task of the older adult, according to Erikson, including "wholeness," emotional integration, and acceptance of physical decline. The others are not developmental tasks described by Erikson.

Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process? Counseling a client who complains of being depressed Providing entertainment for a client on bedrest Arranging for social services to assist with meals for a homebound client Encouraging a client to have regular checkups

Encouraging a client to have regular checkups Explanation: Gould viewed the middle years as a time when adults look inward (ages 35 to 43); accept their lifespan as having definite boundaries, and have a special interest in spouse, friends, and community (ages 43 to 50); and increase their feelings of self-satisfaction, value spouse as a companion, and become more concerned with health (ages 50 to 60). The nursing action that best facilitates this process would be encouraging a client to have regular checkups.

When observing a client diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following? Euphoric Labile Dysphoric Euthymic

Euphoric Explanation: Terms used to describe mood include euthymic (normal), euphoric (elated), labile (changeable), and dysphoric (depressed, disquieted, restless).

A home care nurse is reviewing guidelines for health-related screenings with a 35-year-old patient. What are common screening recommendations for physical examinations? Every 3 years to age 40 and annually from age 40 Annual physical examinations from age 30 Every 2 years to age 50 and annually from age 50 Annual physical examinations from birth

Every 3 years to age 40 and annually from age 40 Explanation: Physical examinations are recommended every 3 years to age 40 and every year from age 40. Annual physical examinations are not required from birth.

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Ptosis Exophthalmos Ectropion Epicanthus

Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumor and inflammation in the orbit.

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record? Exotropia Esotropia Strabismus Presbyopia

Exotropia Explanation: With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.

The middle adult is sometimes called the "sandwich generation". According to Erikson, the developmental task of the middle adult is what? Initiative versus guilt Ego-integrity versus despair Generativity versus stagnation Goal attainment versus crisis

Generativity versus stagnation Explanation: The developmental task of the middle adult is "generativity versus stagnation." They are in a stage of guiding the next generation, accepting their own changes and adjusting to need of aging parents, as well as evaluating their own goals and accomplishments. "Initiative versus guilt" is the developmental task for toddlers. "Ego integrity versus despair" is the developmental task for older adults. "Goal attainment versus crisis" is not a developmental task.

The nurse is assigned to care for a client age 87 years admitted to the medical unit for congestive heart failure. It is the fourth hospital day, and the response to treatment has been good. The client is no longer short of breath and the lung sounds are clearing. There is still a diet restriction of decreased sodium and fluids are limited to no more than 1000 mL per day. The nurse is preparing the client and family for discharge. The nurse's discharge education, in order to promote the older client's health, will include which instructions? Select all that apply. Gradually increase activities as tolerated. Do not use the salt shaker at meals. Increased stress may interfere with recovery. Take several naps during the day.

Gradually increase activities as tolerated. Do not use the salt shaker at meals. Increased stress may interfere with recovery. Explanation: Promoting health for older adults includes ensuring adequate nutrition (e.g., low-fat diet, other diet modifications); balancing calories and activities; planning exercise as a daily activity; and educating the client that illness is a physical and emotional stress and increases the risk for complications. Taking naps will interfere with sleep at night.

A nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech? Ask the client about his education level Give the client the history form to read silently Have the client read a few sentences out loud Assess the client's hearing in both ears

Have the client read a few sentences out loud Explanation: Speech is influenced by experience, education level, and culture. If the client is having trouble with speech, the nurse should ask the client to name objects in the room, read from printed material, or write a sentence. Asking about education level may intimidate the client and project judgment by the nurse. Giving the client a history form to read silently will not assist in assessing speech. Assessing hearing does not help with assessing the ability of the client to formulate words.

The nurse assessing a client understands that which of the following could be due to increased intracranial pressure? Select all that apply. Headache that subsides after arising Blurred vision Ptosis Headache that subsides when lying Difficulty swallowing

Headache that subsides after arising Blurred vision Explanation: A headache that subsides after arising and changes in vision may be related to increased intracranial pressure. Ptosis is seen with weak eye muscles. Difficulty swallowing may be related to brain injury.

Mrs. Jimenez, age 79, became a widow earlier this year and now resides alone in the house that she and her husband shared for 30 years. Her children have encouraged her to move, but she expresses a desire to remain in her home, despite some slight mobility challenges. The nurse who provides occasional home healthcare for Mrs. Jimenez should first propose which of the following? Home modification Assisted living A nursing home Homesharing

Home modification Explanation: Older adults typically express a desire to maintain their existing living relationships and this should be facilitated as long as it is safe. Consequently, the nurse should prioritize Mrs. Jimenez's wishes. Home modification may allow her to maximize her independence and maintain her current living situation in spite of some mobility challenges.

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? Romberg Tandem walking Gait Hop on one foot

Hop on one foot Explanation: Hopping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the client at risk. The nurse needs to ensure the client's safety by standing close by, especially with tandem walking and Romberg's testing because some older clients may have difficulty with maintaining balance. However, these tests would not be omitted. Older clients may have a slow uncertain gait. Testing the client's gate would not be omitted.

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? Hypothalamus Brain stem Cerebral cortex Medulla

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 diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? I must take thyroid hormone replacement medication for the rest of my life. I will complete the entire course of thyroid hormone replacement over six weeks. I must keep my follow up appointments to receive my thyroid hormone injections. I will take my thyroid hormone replacement medication once every week.

I must take thyroid hormone replacement medication for the rest of my life. Explanation: After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.

Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)? II (optic) III (oculomotor) IV (trochlear) VI (abducens)

III (oculomotor) Explanation: Fibers traveling in the oculomotor nerve (CN III) and producing pupillary constriction are part of the parasympathetic nervous system. The iris is also supplied by sympathetic fibers. When these are stimulated, the pupil dilates, and the upper eyelid rises a little, as if from fear. The sympathetic pathway starts in the hypothalamus and passes down through the brainstem and cervical cord into the neck. From there, it follows the carotid artery or its branches into the orbit. A lesion anywhere along this pathway may impair sympathetic effects that dilate the pupil. CN II conveys visual information to the brain; CN IV and VI are involved in moving the eye in its cardinal directions.

A nurse encourages residents of a long-term care facility to continue a similar pattern of behavior and activity that existed in their middle adulthood years to ensure healthy aging. This intervention is based on which aging theory? Identity-continuity theory Disengagement theory Activity theory Life review theory

Identity-continuity theory Explanation: The identity-continuity theory assumes that healthy aging is related to the older adult's ability to continue similar patterns of behavior from young and middle adulthood. Older adults search for emotional integration and acceptance of the past and present, as well as acceptance of physiologic decline without fear of death. Older adults often like to tell stories of past events. This phenomenon, called life review or reminiscence, has been identified worldwide. Disengagement theory maintains that older adults often withdraw from usual roles and become more introspective and self-focused. This withdrawal was theorized as intrinsic and inevitable, necessary for successful aging, and beneficial for both the person and for society.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? Superficial to the sternomastoid In front of the ear In the midline, a few centimeters behind the tip of the mandible At the angle of the mandible

In the midline, a few centimeters behind the tip of the mandible Explanation: The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse? Reassure the mother that this is common in children Inspect the nostrils with an otoscope Assess for allergies to antibiotic Have the child blow the nose to assess drainage

Inspect the nostrils with an otoscope Explanation: Because the drainage is unilateral, the most likely cause is a foreign body obstruction. The nurse should inspect the nostrils for patency and the presence of a foreign body. It is not a normal finding in children to have unilateral foul-smelling drainage from the nose. This child will not need an antibiotic, thus the nurse does not need to assess for allergies to medication. Blowing the nose may or may not dislodge the object and may cause further trauma to the nare.

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Vitreous chamber Aqueous chamber Lacrimal apparatus Sinus

Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding? Coma Stupor Lethargy Obtunded

Lethargy Explanation: Opening the eyes, answering questions, and falling back asleep describes lethargy. Being completely unresponsive to all stimuli with the eyes closed describes a coma. Being awakened with vigorous or painful stimuli describes stupor. Opening the eyes to loud voices, responding slowly with confusion, and being unaware of the environment describes obtunded.

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? Assess for meningitis Look for involvement of other regions of the body Look for a source such as infection in the area that it drains Assess for dietary changes

Look for a source such as infection in the area that it drains Explanation: Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.

A nurse is assessing middle-age adults living in a retirement community. What behavior would the nurse typically see in the middle-age adult? Believes in establishment of self but fears being pulled back into the family Usually substitutes new roles for old roles and perhaps continues formal roles in a new context Looks inward, accepts life span as having definite boundaries, and has special interest in spouse, friends, and community Looks forward but also looks back and begins to reflect on his or her life

Looks inward, accepts life span as having definite boundaries, and has special interest in spouse, friends, and community Explanation: Middle-age adults would be looking inward, accepting the life span as having definite boundaries, and having special interest in spouse, friends, and community. The other options are behaviors of the older adult.

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? Migraine Meningitis Cervical fracture Measles

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

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? Bell's palsy Tension headache Temporal arteritis Migraine headache

Migraine headache Explanation: Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting.

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action? Notify the healthcare provider immediately. Administer intravenous pain medication. Palpate the carotid pulses bilaterally at the same time. Prepare the client for a temporal artery biopsy.

Notify the healthcare provider immediately. Explanation: Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what? Patient advocate Diagnostician Surrogate decision maker Family liaison

Patient advocate Explanation: The nurse may assess the change in the client and will be the advocate and detective, determining when the change occurred and what was new in the treatment.

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing 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? Document the findings in the client's record Perform both the distant and near visual acuity tests Test the pupils for direct and consensual reaction to light Obtain a referral to the ophthalmologist for a complete eye exam

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 healthy 52-year-old client asks the nurse what she can do to maintain her health. Which of the following does the nurse recommend? Have a colonoscopy every 10 years Obtain the zoster vaccine Perform self-examination of the skin every month Have a physical examination every 3 years

Perform self-examination of the skin every month Explanation: Guidelines for health-related screenings, examinations and immunizations for the adult include self-examination of the skin every month; beginning at age 50, colonoscopy every 3-5 years; physical examination every year from age 40; the zoster vaccine is recommended for adults 60 years and older.

A nurse performs a neurological examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet? Plantar flexion Fanning of the toes Dorsiflexion Flexion of the toes

Plantar flexion Explanation: An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes plantar flexion of the feet when stroked. The Babinski reflex in newborns is when the bottom of the foot is stroked, the toes fan out. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion is part of the range of motion for the foot.

A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client? Exotropia Esotropia Strabismus Presbyopia

Presbyopia Explanation: Presbyopia, which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from the eyes to focus on the print. It is caused by decreased accommodation and is a common condition in clients over 45 years of age. With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes.

When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; dilation on distant gaze Pupillary dilation on near gaze; constriction on distant gaze Pupillary constriction on near gaze; dilation on distant gaze Pupillary constriction on near gaze; constriction on distant gaze

Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze.

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? Dark pink, moist, & free of discharge Pale pink, swollen, with watery exudate Bluish gray, swollen, with watery exudate Red, swollen, with purulent discharge

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.

An client 81 years of age is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the client wandering in the hall. He says he is looking for his wife. What should the nursing approach should be? Use a matter-of-fact attitude and gently help him back to his room. Remind him that he must not get up unassisted and should stay in his room at night. Remind him of where he is and assess why he is having difficulty sleeping. Allow him to sleep in the recliner in the day-room, so he will not disturb other clients.

Remind him of where he is and assess why he is having difficulty sleeping. Explanation: Reminding the client where he is will help orient him to his surroundings. Assessment is needed to determine any need that may be disturbing the client, such as the need to use the bathroom, feeling cold/warm, etc. The other responses do not include orienting the disoriented/confused client.

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? Right knee +1; Left knee 0 Right knee +2; Left knee +1 Right knee +3; Left knee +2 Right knee +4; Left knee +3

Right knee +2; Left knee +1 Explanation: A normal reflex response is documented as being +2. A diminished reflex response is documented as being +1. A 0 is no reflex response. A +3 is a brisker than average response. A +4 is a very brisk response.

What intervention will the nurse implement initially for a client who has reported experiencing unexplained, severe neck pain for more than 2 months? Request a consult with physical therapy. Provide education regarding exercises that focus on strengthening neck muscles. Screen for possible depression. Inquire about possible pain medication abuse.

Screen for possible depression. Explanation: Unexplained conditions lasting more than 6 weeks are increasingly recognized as chronic disorders that should prompt screening for depression, anxiety, or both. While the remaining options may prove to be appropriate, the screening is the initial intervention.

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She obtains a 20% correct score at 100 feet. She can accurately name 20% of the letters at 20 feet. She can see at 20 feet what a normal person could see at 100 feet. She can see at 100 feet what a normal person could see at 20 feet.

She can see at 20 feet what a normal person could see at 100 feet. Explanation: The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet.

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? Sitting with the head erect and at the eye level of the nurse Tilting the head backwards, with the neck flexed Semi-recumbent position, with the chin lifted Prone, with arms relaxed at the sides

Sitting 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 and palpation of the sinuses more difficult for the examiner.

In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client? Sleep deprivation Social isolation Grieving Noncompliance

Sleep deprivation Explanation: A common problem in clients with dementia is sundowning syndrome in which an older adult habitually becomes confused, restless, and agitated after dark and does not sleep. Implementing the nursing diagnosis of sleep deprivation will help the client obtain adequate sleep at night and awaken refreshed. Social isolation, grieving, and noncompliance are diagnoses that could be related to dementia but not sundowning.

A public health nurse is participating in a health fair that is being held at a local community center. The nurse should encourage adult participants to completely eliminate which of the following from their diet and lifestyle? Smoking Alcohol Salt Cholesterol

Smoking Explanation: Alcohol, salt, and cholesterol all have the potential to cause harm when used in excess. However, moderate and conscientious intake of each is not unhealthy, and complete elimination of cholesterol or salt from the diet would in fact be harmful. Smoking, however, is never a benign activity and even "moderate" smoking should be discontinued.

The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision? Allen Snellen E Ishihara PERRLA

Snellen E Explanation: The Snellen E chart can be used for people who cannot read or speak English.

x A nurse has attended an inservice workshop that addressed the phenomenon of ageism in the health care system. Which of the following practices is indicative of ageism? Implementing falls prevention measures in a setting where older adults receive care Providing slightly smaller servings of food for clients who are elderly Speaking to older adults with the presumption that they have mild cognitive deficits Assessing the skin turgor of an older adult differently than that of a younger adult

Speaking to older adults with the presumption that they have mild cognitive deficits Explanation: Accommodation of normal, age-related changes such as decreased skin turgor and slightly decreased nutritional needs is not an indication of ageism. Similarly, safety measures are unlikely to be motivated by ageist beliefs. Assuming that all older adults have cognitively deficits, however, is an indication of ageism.

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? Sternocleidomastoid Trapezius Masseter Temporalis

Sternocleidomastoid Explanation: The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The masseter and temporalis muscles are involved in raising and lowering the mandible during mastication (chewing).

x When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing? Suicide attempts Suicide means Suicide risk Suicide plan

Suicide risk Explanation: Suicide risk is assessed by asking, "Do you have any thoughts of wanting to harm or kill yourself?" This question does not assess attempts at suicide, means of suicide, or plans of suicide.

Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? Ask the client to shrug both shoulders upward against the examiner's hands. Ask the client to raise his or her eyebrows, frown, and close both eyes tightly. Test the client's ability to identify a familiar smell with his or her eyes closed. Test the client's hearing for lateralization and bone and air conduction.

Test the client's hearing for lateralization and bone and air conduction. Explanation: CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing. Shoulder shrugging tests CN XI; frowning and closing the eyes depend on CN VII. CN I is tested by assessing the client's ability to identify smells.

Which of the following assessment findings of a male client age 77 years should signal the nurse to a potentially pathologic finding, rather than a normal age-related change? The client is oriented to person and place but is unsure of the month. The client states that his urine stream is less strong than in the past. The client claims to hear high-pitched sounds less clearly than earlier in life. The client's gait is slow and his posture appears stooped.

The client is oriented to person and place but is unsure of the month. Explanation: Age-related physiologic changes include a weakening of bladder emptying, presbycusis, and a slow gait that may be accompanied by stooped posture. Disorientation to time, however, should always prompt the nurse to perform further assessment and should never be considered a normal accompaniment to the aging process.

A nurse is preparing a presentation for a group of older adults about health promotion. Which statistic would the nurse need to keep in mind about this group? Life expectancy has increased for men but not for women. The group experiencing the largest growth is those 85 years of age and older. The number of older adults has begun to plateau since the year 2000. The older adult population appears to be younger than in the past.

The group experiencing the largest growth is those 85 years of age and older. Explanation: The older population itself is older than it has been in the past. In 2012, the 65-74 age range was more than 10 times larger than in 1900; however, in contrast, the 75-84 age group was 17 times larger, and those age 85 years or older was 48 times larger. Life expectancy has increased for both men and women. Worldwide, the number of older adults has grown exponentially. Since 1900, the percentage of individuals 65 years or older has tripled, and the number has increased over 13 times. The older adult population itself is older than it has been in the past.

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding? The boy requires assessment of his thyroid gland. There is an inflammatory response in the musculature of the boy's neck. The tissue underlying the nodes is infected. There is an infection in the area that these nodes drain.

There is an infection in the area that these nodes drain. Explanation: Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect? Diphtheria Kaposi's sarcoma Torus palatinus Thrush

Thrush Explanation: Thick, white plaques that are partially adherent to the oral mucosa are associated with thrush. HIV and AIDS are predisposing factors. People with HIV and AIDS are also prone to Kaposi's sarcoma, but these lesions are typically deep purple. Diphtheria causes a dull redness in the throat, and a torus palatinus is a bony growth in the hard palate.

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the tongue? Use a square gauze pad to hold the client's tongue to each side. Use a penlight and tongue depressor to retract the lips. Put on gloves and retract the client's lips and cheeks. Ask the client to stick the tongue out between the lips

Use a square gauze pad to hold the client's tongue to each side. Explanation: The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's tongue to each side. Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. Putting on gloves and retracting the client's lips and cheeks is a technique used to examine the gums and teeth. Sticking the tongue out between the lips only allows visualization of the anterior portion of the tongue.

The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach? Requires little energy by the nurse to complete Is the easiest and shortest assessment to complete Validates the information the client provides during the rest of the assessment Ensures that this part of the assessment is completed before the client becomes fatigued

Validates the information the client provides during the rest of the assessment Explanation: Many assess mental status at the beginning of a head-to-toe assessment because it provides clues regarding the validity of the subjective information provided by the client throughout the examination. This assessment is not done first because it takes less energy for the nurse to complete it. This assessment can be quite lengthy. It is not done first because the client may become fatigued.

The functional reflex that allows the eyes to focus on near objects is termed pupillary reflex. accommodation. refraction. indirect reflex.

accommodation. Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for parotid gland enlargement. acromegaly. Paget disease. Cushing syndrome.

acromegaly. Explanation: The skull and facial bones are larger and thicker in acromegaly.

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first explain to the client why the assessment is necessary. ask the client if touching the head is permissible. determine whether the client desires a family member present. examine the lymph nodes of the neck before examining the head.

ask the client if touching the head is permissible. Explanation: Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head.

A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms? brainstem cerebellum frontal lobe parietal lobe

cerebellum Explanation: The cerebellum lies at the base of the brain, coordinates all movements and helps maintain the body upright in space. The brainstem regulates respiratory and cardiac function and includes the reticular activating system (RAS), and the midbrain, pons, and medulla oblongata. The frontal lobe is responsible for higher intellectual function, speech production, and ipsilateral motor control. The parietal lobe is the primary somatic sensory area.

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment? characteristic symptoms associated manifestations relieving factors location

characteristic symptoms Explanation: Characteristic symptoms include having the client rate the level of pain as this provides information about the severity. This subjective information is categorized as a characteristic symptom. Information about anything else that the client may be experiencing during the headache (for example, nausea or blurred vision) should be documented in associated manifestations. Relieving factors provides information about anything that the client has attempted to relieve the symptoms. The location provides subjective information about where the headache is localized and pain radiates.

The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because depression and dementia are one in the same disorder. finding out why she is depressed will help determine the cause of her dementia. depression often mimics signs and symptoms of dementia. it is the most accurate tool to determine the stage of dementia.

depression often mimics signs and symptoms of dementia. Explanation: The Geriatric Depression Scale is used if depression is suspected in the older client. Read the questions to the client if the client cannot read.

The nurse is planning to assess a client's near vision. Which technique should be used? shine a light on the bridge of the nose have the client read newspaper print held 14 inches from the eyes ask the client to move the eyes in the direction of a moving finger have the client stand 20 feet from a wall chart and read the letters after covering one eye

have the client read newspaper print held 14 inches from the eyes Explanation: Near vision is tested by asking the client to read newspaper print held 14 inches from the eyes. Shining a light on the bridge of the nose tests the corneal light reflex. Moving the eyes in the direction of a moving finger tests for extraocular movements. Having the client read letters on a wall chart tests for central and distance vision.

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem? angular cheilitis herpes simplex actinic cheilitis angioedema

herpes simplex Explanation: The herpes simplex virus produces recurrent vesicular eruptions of the lips and surrounding skin. Angular cheilitis is the presence of fissures at the edges of the mouth. Actinic cheilitis affects the lower lip and is characterized by scales, thickening, and eversion of the lip tissue. Angioedema is a diffuse swelling of the dermis and subcutaneous tissue.

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely? hypothyroidism gingivitis dysphagia aphthous ulcers

hypothyroidism Explanation: Hoarseness lasting longer than two weeks accompanied by the additional reported symptoms of fatigue and weight gain suggest hypothyroidism. Gingivitis is an inflammation of the gums that often results in bleeding. Dysphagia is a medical term used to describe difficulty swallowing. This can be due to a neuromuscular or oropharyngeal deficit. Hoarseness can accompany dysphagia; however, weight gain and fatigue do not. Aphthous ulcers are a common condition that are restricted to the oral cavity. Commonly called "canker sores," they may be associated with autoimmune problems that create a predisposition to developing oral ulcers.

An auditory hallucination is considered an alteration in which component of the mental health assessment? perceptions thought processes affect insight

perceptions Explanation: Perception is the sensory awareness of objects in the environment and their interrelationships (external stimuli). Perception also refers to internal stimuli such as dreams or hallucinations. Thought processes involve the logic, coherence, and relevance of a client's thought as it leads to selected goals or how people think. Affect is the observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor. Insight is considered the awareness that symptoms or disturbed behaviors are normal or abnormal, for example, distinguishing between daydreams and hallucinations that seem real.

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? onset location treatment relieving factors

relieving factors Explanation: Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away. Onset refers to when the migraine started. Location helps determine what part of the client's head the pain is localized within or where it radiates. Treatment refers to any assessment, support, or care the client has received from various health care providers.

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

soft palate. Explanation: The roof of the oral cavity is formed by the anterior hard palate and the posterior soft palate.

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates deep coma. severe impairment. no verbal response. some impairment.

some impairment. Explanation: The points associated with the Glasgow Coma Scale are determined to assess levels of consciousness and coma. Points are allotted for each of the 3 areas: eye opening, verbal response and motor responses. A score of 13 indicates some impairment.