Neuro & mobility
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? A) acute bacterial sinusitis B) allergic rhinitis C) rhinitis medicamentosa D) epistaxis
A
A client who has experienced a stroke has no eye or verbal response but withdraws from painful stimuli. How would the nurse score these responses using the Glasgow Coma Scale? A) 6 B) 8 C) 10 D) 12
A
A client with a diagnosis of type 1 diabetes is admitted to the hospital with acute symptomatic seizures. Given the client's underlying condition, what would be the most likely cause of this type of seizure? A) hyperglycemia B) ventricular tachycardia C) syncope D) headache
A
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? A) characteristic symptoms B) associated manifestations C) relieving factors D) location
A
A nurse assesses a young adult client who lost consciousness after a head-to-head collision while playing football. Which question should the nurse ask in order to determine characteristic symptoms of the head trauma? A) "Do you have a history of seizures?" B) "Do you feel like vomiting?" C) "Are you feeling dizzy?" D) "How long were you unconscious?"
A
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) "Walk heel to toe." C) "Walk on your toes then on your heels." D) "Hop on one spot."
A
A nurse is assessing a client with referred otalgia. In order to identify the associated manifestations of this problem, the nurse should ask which question? A) "Have you had any recent infectious contacts?" B) "Does pain medication help?" C) "Who did you see about this problem in the past?" D) "How long have you been experiencing pain?"
A
A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client has slurred speech, although language is intact. Which disorder of speech is the nurse observing in this client? A) dysarthria B) aphasia C) dysphonia D) aphonia
A
A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms? A) exercising the legs B) resting the legs C) taking pain medication D) taking antidepressant medication
A
When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do? A) Smile. B) Clench the teeth. C) Cover one eye. D) Smell coffee beans.
A
While the nurse is obtaining a client's health history regarding the head and neck, the client reports having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next? A) "Do you have difficulty swallowing?" B) "How long have you experienced discomfort from the lump?" C) "When did you first notice the lump?" D) "Is there more than one lump?"
A
In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? (Select all that apply.) A) gloves B) penlight C) tongue depressor D) speculum E) tuning fork
A,B,C
Which body functions are related to the hypothalamus? Select all that apply. A) withdrawing a hand from a hot stove B) sweating on a hot day C) feeling worried about an exam D) experiencing a regular menstrual cycle E) learning a new dance move
B,C,D
A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client? A) Whisper hearing test B) Rubbing fingers test C) Formal hearing test D) Tuning fork test
C
A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac? A) Mucopurulent fluid is observed near the sac. B) There is excessive tearing in the right eye. C) The area around the sac is inflamed. D) The client reports experiencing floaters.
C
When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination? A) to assist the client to feel more comfortable B) to prevent further dehydration C) to observe the movement of the thyroid gland D) to promote the nurse-client relationship
C
Which assessment notation describes a client's level of consciousness? A) "Client was inattentive to the questions being asked." B) "Client answered questions both logically and coherently." C) "Client was alert and cooperative during the assessment." D) "Client demonstrated difficulty with recalling events occurring this morning."
C
Which statement by the nurse indicates the best understanding of the purpose of an eye-related health history? A) "The history allows the client to discuss their vision-related problems." B) "The nurse is able to visualize the client's eye with the benefit of an ophthalmoscope." C) "Broad, open-ended questions provide an opportunity to identify changes in the client's eyes." D) "The history encourages the client to reflect upon the state of client's eyes and vision."
C
Which statement represents a clanging speech pattern? A) "The yard is covered in gukkers." B) "I love flowers, I love beer, I love January, I love loving." C) "Peas are good. Trees are wood. I'd leave if I could." D) "See that nurse, it's cold in here, my mother likes pink flowers."
C
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? A) onset B) location C) treatment D) relieving factors
D
During the health history of the eye, a patient tells the nurse about occasional floaters within the field of vision. The nurse identifies the structure causing this symptom to be from the: A) Retina B) Brainstem C) Cerebellum D) Vitreous humor
D
During the health history of the nose and sinuses, a patient reports having rhinorrhea. What question would the nurse ask to determine associated manifestations of this symptom? A) "In which side does it occur? B) "How long does it last?" C) "What color is the drainage?" D) "Are there any other symptoms?"
D
When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems? A) Rhinorrhea B) Fever C) Headache D) Vertigo
D
When the nurse is obtaining the health history of the nose and sinuses, a client reports symptoms of rhinorrhea. Which question should the nurse ask to determine associated manifestations of this symptom? A) "In which side does it occur" B) "How long does it last?" C) "What color is the drainage?" D) "Have you had a sore throat?"
D
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition? A) malignancy B) inflammation C) enlargement D) hypothyroidism
A
The nurse is preparing to use an otoscope to examine a client's ear canal and drum. With which of the following grip techniques should the nurse use to hold the otoscope? A) Pencil B) Hammer C) Wrench D) Handshake
A
When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point? A) Mobile phones should only be used if there is a hands-free option available. B) A car seat should only be installed in the front if there are passenger airbags available. C) Refrain from taking any medication prior to operating a motor vehicle. D) Helmets can obscure vision when riding all-terrain vehicles and should be avoided.
A
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) Alteration in the perception of position B) Changes in the perception of vibration C) Change in pain perception D) Alteration in temperature sense E) Loss of depth perception
A,B
The nurse is preparing to assess a client's cranial nerves using a screening neurologic examination. Which of the following should the nurse include in this assessment? (Select all that apply.) A) Visual acuity B) Eye movements C) Hearing D) Finger proprioception E) Facial strength
A,B,C,E
The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first? A) Displace the trachea to the right. B) Listen over the thyroid with a stethoscope. C) Ask the patient to sip and swallow water. D) Ask the client to lie down for further assessment
C
When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals? A) slightly darker fovea is just discernible B) no light reflex is visible C) fundus is grayish brown with a purplish cast D) the lower field of the fundus has characteristic stripes
C
When considering high-yield screening data, which question would likely gather the most relevant information concerning a client's mental status? A) "Have any of your first-degree relatives ever been diagnosed with anxiety?" B) "Do you think that you have experienced any depression during the last 6 months?" C) "Over the last 2 weeks, have your become less interested in your hobbies?" D) "What types of things tend to trigger your anxieties?"
C
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? A) Assess the client's blood pressure. B) Provide medication for pain relief. C) Inquire about family history of headaches. D) Review the client's medical record.
A
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? A) hypothyroidism B) gingivitis C) dysphagia D) apthous ulcers
A
A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve? A) Trigeminal B) Facial C) Glossopharyngeal D) Vagus
A
A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem? A) "Have you had any recent trauma to the inside of your ear?" B) "Do you hear ringing in your ears?" C) "Are their times when you feel dizzy?" D) "Have you ever taken medication that is ototoxic?"
A
A nurse is preparing a community education session on hearing loss. Which information should the nurse include? A) Hearing loss can lead to mental health problems. B) All ethnic groups experience hearing loss in the same way. C) In order to hold a driver's license, hearing must be tested regularly. D) Hearing loss typically begins after the age of 40.
A
A patient is diagnosed with glaucoma affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis? A) Increased intraocular pressure B) Sluggish pupillary reaction C) Displaced optic nerve D) Opaque lens
A
An auditory hallucination is considered an alteration in which component of the mental health assessment? A) perceptions B) thought processes C) affect D) insight
A
An older patient is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this patient? A) "What is today's date?" B) "What are the parts of a watch?" C) "Do you think that life is not worth living?" D) "What do you think is wrong?"
A
The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? A) Always use seat belts. B) Wear nonslip shoes in the house. C) Avoid risky activities such as snowboarding D) Use of guns should be supervised by an adult
A
The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point? A) "Effective blood glucose regulation can prevent this problem." B) "You will be able to observe symptoms of this problem early on." C) "Testing for this problem will involve having blood tests only." D) "Pain is the only sensation associated with this problem."
A
The nurse should make it a priority to assess which client for papilledema? A) a 45-year-old suspected of experiencing a subarachnoid hemorrhage B) an 80-year-old diagnosed with chronic open-angle glaucoma C) a 12-year-old demonstrating a deviated left eye D) a 56-year-old reporting double vision
A
The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely? A) hyperthyroidism B) thyroid cyst C) Hashimoto thyroiditis D) benign tumor
A
When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction? A) Up B) Down C) To the right D) To the left
A
When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask? A) "Can you tell me where you are right now?" B) "Do you feel like crying often?" C) "Do you have a history of psychotic disorder?" D) "Can you tell me about your mood today?"
A
A family member of a client recovering from a traumatic brain injury asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.) A) Use rails on stairs B) Remove extension cords from high traffic areas C) Avoid the use of throw rugs. D) Always sit to have a shower E) Avoid taking medications that cause faintness
A,B,C
A parent reports her preschool-aged child has been having epistaxis every 2 to 3 days for the past month. Which questions should the nurse ask to determine the possible causes? Select all that apply. A) "Does your child have painless bruising?" B) "Does your child pick his nose?" C) "Is your child taking any medications?" D) "Has your child had a recent fever?" E) "Does your child have difficulty breathing through his nose?"
A,B,C
What information, acquired during an eye assessment and history, would the nurse document as lifestyle habits?(Select all that apply.) A) Has smoked for last 12 years B) Uses sunglasses when outdoors C) Uses protective eyewear when appropriate D) Wears disposable contact lens E) Eyes itch when in a smoky environment
A,B,C
When assessing the eye, the nurse recognizes that which physical structures of the face limit the normal visual field that a client can experience? Select all that apply. A) the brow B) the medial aspect of the nose C) the cheek D) the lashes E) the lacrimal puncta
A,B,C
When the nurse is assessing a client who is comatose, which actions should be included in the assessment? Select all that apply. A) determining level of consciousness B) assessing airway, circulation, and breathing C) obtaining the medical history D) repositioning of the neck E) checking pupillary light reflex
A,B,C
Which characteristic observed in a recently widowed patient should prompt the nurse to assess the patient for possible early depression? (Select all that apply.) A) Insomnia B) Impaired decision making C) Anhedonia D) Tearfulness E) Reminiscing about their spouse
A,B,C
An older adult client reports lacking the desire to eat. The client also reports having discomfort from dentures and a persistently dry mouth. Which questions should the nurse include when taking the health history for this client? (Select all that apply.) A) "When was your last dental examination?" B) "Can you tell me what you eat in a day?" C) "How much water do you drink in a day?" D) "Which medications do you take?" E) "Have you noticed any bluish-black swelling under your tongue?"
A,B,C,D
Which questions asked by the nurse demonstrate an understanding of the various coexisting conditions that contribute to the mental status of a client? Select all that apply. A) "Are you using any substances to help manage your panic attacks?" B) "Could your anxiety be a result of the verbal abuse you are experiencing?" C) "Would you say that your diabetes has contributed to making you depressed?" D) "You seem very angry today; are you particularly anxious about something?" E) "Are you worried about how you will pay for this hospital stay?"
A,B,C,D
A client reports having difficulty smelling food aromas over the past month. Which questions should the nurse include in the health history? (Select all that apply.) A) "Do you smoke cigarettes?' B) "Have you had a cold or flu recently?" C) "Have you had nasal surgery before?" D) "Do you have frequent nosebleeds?" E) "Are you taking any antibiotic medication?"
A,B,C,E
The nurse is planning instructions for a patient with a broken nose. What teaching will be included to address the alterations in nasal function? (Select all that apply.) A) How to breathe through the mouth B) Importance to increase oral fluids C) Safety measures because of a loss of smell D) Expect a sore throat and difficulty swallowing E) Remind that the voice may sound different
A,B,C,E
The nurse is planning to provide discharge teaching for a client with surgical repair of a septal perforation. Which points should be included to address the expected alterations in nasal function? Select all that apply. A) techniques for breathing effectively through the mouth B) increasing oral fluid intake C) awareness of loss of smell D) management of difficulty swallowing E) anticipating short term hoarseness of the voice
A,B,C,E
When considering eye safety, what instructions should the nurse provide to a patient newly prescribed contact lenses? (Select all that apply.) A) Do not share lenses. B) Keep the lenses clean. C) Wash hands before inserting or removing the lenses. D) Inspect the lenses every week for scratches or damage. E) Discard unused portions of contact solutions at the expiration date.
A,B,C,E
During a physical examination of the head and neck, a client reports frequently feeling cold. What additional questions should the nurse ask for more information about the client's symptoms? (Select all that apply.) A) "Do you dress more warmly than other people? B) "Do you use more blankets that others at home? C) "Do you perspire more than others?" D) "Do you perspire less than others?" E) "Have you lost weight recently?"
A,B,D
The nurse is preparing to conduct a mental status examination with a patient. Which areas will the nurse include when assessing the patient's appearance and behavior? (Select all that apply.) A) Level of consciousness B) Posture C) Articulation of words D) Facial expressions E) Orientation
A,B,D
Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply). A) When did you first notice the lump? B) How recently have you consumed alcohol? C) Do you have family members that experience lumps? D) Has the lump changed? E) Is it painful to touch?
A,B,D
After conducting a screening neurological examination, the nurse identifies the client is at risk for a stroke. Which of the following client education should the nurse provide at this time?(Select all that apply.) A) Begin smoking cessation B) Take prescribed antihypertensive medication C) Limit exercise to 10 minutes daily D) Warning signs of a stroke E) Use continuous positive airway pressure (CPAP) device as prescribed.
A,B,D,E
A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? Select all that apply. A) a throw rug in the dining room B) bathtubs in all bathrooms C) no gate at the top and bottom of the stairs D) missing window guards E) a television cord runs across the floor
A,B,E
What tools will the nurse use to assess a patient's for normal attention? (Select all that apply.) A) Number list B) Calculations C) Serial 7s D) Proverbs E) Spelling backward
A,C,E
A patient is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this patient's symptom? (Select all that apply.) A) Press up on the frontal sinuses from under the bony brows. B) Press down on the head. C) Press up on the area next to the ear. D) Press up on the maxillary sinuses. E) Press down on the lower jaw.
A,D
A client reports occasionally experiencing hoarseness. In response to this statement, the nurse asks, "What makes the hoarseness go away?" Which characteristic of the client's symptom is the nurse assessing? A) treatment B) relieving factors C) duration D) onset
B
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? A) Right knee +1; Left knee 0 B) Right knee +2; Left knee +1 C) Right knee +3; Left knee +2 D) Right knee +4; Left knee +3
B
During a health history, a patient tells the nurse about having pain that has lasted for longer than 6 weeks. What action should the nurse make at this time? A) Begin high-yield screening questions. B) Conduct a mental health screening. C) Document the information. D) Ask what medication is used for relief.
B
During the health history of the musculoskeletal system, the client reports having low back pain that radiates into the leg with numbness and tingling. The nurse should further assess for spinal stenosis when the client makes which of the following statements? A) "The pain improves when I exercise" B) "The pain improves when I am leaning over a shopping cart" C) " The pain is relieved when I cough or sneeze" D) "The pain is relieved when I am sitting to have a bowel movement"
B
During the physical examination of a patient's eyes, the nurse asks the patient to follow the tracing of a giant H with the eyes. What function is the nurse assessing in this patient? A) Pupil reaction to light B) Extraocular movements C) Convergence D) Corneal light reflex
B
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? A) angular cheilitis B) herpes simplex C) actinic cheilitis D) angioedema
B
Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)? A) II (optic) B) III (oculomotor) C) IV (trochlear) D) VI (abducens)
B
In order to effectively examine a patient's eyes with an ophthalmoscope, the nurse should follow which procedure related to this piece of equipment? A) Remove eyeglasses before looking into the ophthalmoscope. B) Place the ophthalmoscope in the right hand and look through the right eye. C) Place the ophthalmoscope in the left hand and look through the right eye. D) Close the eye that is not looking through the ophthalmoscope during the examination.
B
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 state the current date and place B) Instruct the client to flex and extend the right elbow C) Instruct the client to smile D) Ask the client to close the eyes
B
What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart that is mounted on the examination room wall? A) Near vision B) Distant vision C) Peripheral vision D) External eye structures
B
When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head? A) Sclera color B) Hair color C) Nasal mucosa color D) Facial skin color
B
When the client reports a problem associated with the drainage of tears from the left eye, the nurse would focus the eye assessment on which eye structure? A) lacrimal gland B) lacrimal puncta C) lacrimal sac D) nasolacrimal duct
B
Which nursing intervention does a client who is in the obtunded level of consciousness require most? A) gently shaking B) frequent reorientation C) protection from injury D) regular respiratory assessment
B
Which question should the nurse ask when assessing a client for a possible detached retina? A) "Is your vision loss located in the center of your view of vision?" B) "Are you seeing flashing lights?" C) "Can you see objects on the outer edges of your field of vision?" D) "Is the vision in both of your eyes affected?"
B
A mental status examination consists of various components. Which assessment data is associated with cognitive function? Select all that apply. A) Client is dressed appropriately for the weather. B) Client is able to successfully multiple 24 times 32. C) Client correctly names the last three presidents of the United States. D) Client's verbal skills are appropriate for age. E) Client reports frequently seeing a dead parent.
B,C
When a client is being evaluated for possible somatic symptoms, which assessment questions should the nurse ask to assess for common functional syndromes? Select all that apply. A) "Do you have a history of experiencing a tightness in your chest?" B) "Would you say that you are chronically fatigued?" C) "Have you ever been diagnosed with irritable bowel syndrome?" D) "Would you say that you experience an uncommon amount of muscle pain?" E) "Can you tell me more about the jaw pain you have reported?"
B,C,D,E
Which client statements suggest to the nurse that the client is experiencing a somatic symptom? Select all that apply. A) "I've been so nervous since living through that tornado." B) "I can't recall doing anything to cause this back pain I've been having." C) "My partner complains that I'm just not as interested in sex as I was before the baby was born." D) "Since my mother died, I've been feeling really depressed." E) "I can't have this headache; I've got final exams tomorrow."
B,C,E
A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion? A) peripheral nervous system B) autonomic nervous system C) sympathetic nervous system D) somatic nervous system
C
During a health history, the nurse notes that an older patient answers common questions inappropriately. What should the nurse now focus the assessment on to obtain more information about this finding? A) Mood B) Cognition C) Aphasia D) Abstract thinking
C
During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve? A) I B) V C) VIII D) XII
C
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? A) Superficial to the sternomastoid B) In front of the ear C) In the midline, a few centimeters behind the tip of the mandible D) At the angle of the mandible
C
The nurse is documenting the findings from a mental status examination. After stating the patient's appearance and behavior, what should the nurse document next? A) Loss of short-term memory B) Appears sad C) Articulates needs verbally D) Feeling that doctors are drug pushers
C
The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this examination, which tool should the nurse use? A) tongue blade B) gloves C) gauze pad D) penlight
C
What intervention will the nurse implement initially for a client who has reported experiencing unexplained, severe neck pain for more than 6 months? A) Request a consult with physical therapy. B) Provide education regarding exercises that focus on strengthening neck muscles. C) Screen for possible depression. D) Inquire about possible pain medication abuse.
C
When a client reports a sudden but painless loss of vision in the right eye, which question should the nurse ask? A) "Have you ever been diagnosed with acute angle closure glaucoma?" B) "May I assess your eye for a possible corneal ulcer?" C) "Do you have a history of diabetes?" D) "Are you currently prescribed a steroid medication?"
C
A client reports, "There is something in my left eye that is causing me considerable discomfort." What initial step should the nurse take when everting the client's upper eyelid in order to search for the foreign body? A) Place a tongue blade at least 1 cm above the right lid margin. B) Raise the upper eyelid slightly to cause the eyelashes to protrude. C) Grasp the upper eyelashes, and gently pull down and forward. D) Ask the client to look down toward the left cheek.
D
A nurse prepares an educational session on the importance of oral hygiene. Which teaching tip should be included in the section about preventing gingivitis? A) Brushing more than twice per day irritates the gums. B) A firm toothbrush is most effective in plaque removal. C) Avoid flossing if there is bleeding at the gumline. D) Ensure that dental restorations fit well.
D
A patient is concerned that the spouse is planning to commit suicide. What can the nurse respond to this patient? A) "People who commit suicide do not regularly see a physician." B) "Two-thirds of attempted suicides are unsuccessful." C) "A chronic illness is the most reliable indicator for a suicide attempt." D) "Firearms in the home and substance abuse are risk factors."
D
A patient tells the nurse not to bother with an assessment since, "my condition is "hopeless"." This response should cause the nurse to perform which type of assessment? A) Mental health screening B) Appearance and behavior C) Thought and perceptions D) High-yield screening
D
An older adult client who wears dentures reports having soreness of the gums. Which intervention should the nurse recommend to the client to alleviate this problem? A) Avoid excessive intake of sugary foods. B) Use toothpaste containing fluoride. C) Have a dental examination every 2 years. D) Massage the gums daily.
D
During the health history of the nervous system, a client report having a history of generalized seizures. Which of the following should the nurse ask the client to determine characteristic symptoms of the seizures? A) "How old were you when you had your first seizure?" B) "When was your last seizure?" C) "How often do the seizures occur?" D) "What happens after the seizure?"
D
While conducting a mental status history, the nurse notes that the patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important? A) Appearance and behavior B) Mood C) Thoughts and perceptions D) Speech and language
D
While the client is sitting quietly, the thumb and index finger of the left hand are moving in a circular motion. The nurse identifies this finding as which of the following problems? A) A postural tremor B) An intention tremor C) Myoclonus D) A resting tremor
D
While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse? A) Myopia B) Presbyopia C) Direct reaction D) Consensual reaction
D
What information should the nurse include when documenting the data associated with the physical examination of a patient's eyes? (Select all that apply.) A) Presence of double vision B) Trauma to the eye C) Diagnosis of diabetes D) Shape and size of the pupils E) Appearance of the optic disc
D,E