NR 302 Final Exam Review

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile remits. Which action by the nursing student indicated a need for further teaching? 1. Palpating over the lung apices in the supraclavicular area 2. Asking the client to repeat the word ninety-nine during palpation 3. Palpating over the breast tissue to assess and compare vibrations from 1 side to the other 4. Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine

3. Palpating over the breast tissue to assess and compare vibrations from 1 side to the other bc sound will be muffled

A client is diagnosed with external otitis (swimmers ear). Which finding would the nurse expect to note on the assessment of the client? 1. A wider than normal ear canal 2. A pearly gray tympanic membrane 3. Redness and swelling in the ear canal 4. An excessive amount of cerement lodged in the ear canal

3. Redness and swelling in the ear canal

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminishe

3. Wheezes high pitched squeaking sound

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? 1. You have normal vision 2. You have some degree of blindness 3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft 4. You can read at a distance of 30 ft what a person with normal vision can read at 20 ft

3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft

Leukoplakia

chalky white, thick, raised patch on sides of tongue; precancerous does not scrape off. chronic smokers

Annular Lesions

circular, begins in center and spreads to periphery

atelectasis

collapsed lung

When assessing pupillary light reflex, the nurse advances a light to the pt's right eye, approaching from the side. The nurse notes that the right pupil _________, and the left pupil simultaneously ________ also known as _________________

constricts, constricts, accomodation

strabismus

crossed eyes

When assessing for accommodation, a patient's pupils will ___ when focusing on a distant object versus ______ and _______ when the patient focuses on a near object

dilate, converge and constrict

kyphosis

excessive outward curvature of the spine, causing hunching of the back. can be normal part of aging

Snellen Eye chart

eye chart 20 feet

Cranial nerve III, IV, VI

eye movements

clubbing of nails

finding in the nails that indicates chronic hypoxia 180 degrees

Macule

flat, colored spot on the skin (freckle)

nystagmus

Involuntary rapid eye movements

leukoedema

benign, milky, bluish-white opaque appearance of the buccal mucosa that occurs commonly in African Americans

vesicle

blister

Ecchymosis

bruise

Apex of lungs

top of lungs

Hypothyroidism

underactivity of the thyroid gland (cold intolerance, edematous face, cool skin, slow reflexes

Cranial Nerve II

visual acuity, pupillary light reflex

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this exam? 1. Pull pinna up and back before inserting the speculum 2. Pull the earlobe down and back before inserting speculum 3. Tilt the client's head forward and down before inserting the speculum 4. Use the smallest speculum available to decrease discomfort

1. Pull pinna up and back before inserting the speculum

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? 1. The major bronchi 2. The trachea and larynx 3. The peripheral lung fields 4. The lower posterior thorax

1. The major bronchi inspiratory=expiratory

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? 1. A tuning fork 2. A stethoscope 3. A tongue blade 4. A reflex hammer

1. A tuning fork

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. Increasing rate and depth of respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration

1. Increasing rate and depth of respirations with periods of apnea. pg. 434

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? 1. Number of pack-years 2. Desire to quit smoking 3. Brand of cigarettes used 4. Number of past attempts to quit smoking

1. Number of pack-years how heavy of a smoker were they

The nurse performing a neurological exam is assessing eye movement to evaluate cranial nerves III, IV, VI. Using a flashlight, the nurse would perform which action to obtain assessment data? 1. turn the flashlight on directly in front of the eye and watch for a response 2. Ask the client to follow the flashlight through the 6 cardinal positions of gaze 3. instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye 4. Check pupil size, then ask the client to alternate looking at the flashlight and the examiner's finger

2. Ask the client to follow the flashlight through the 6 cardinal positions of gaze

The nurse in a health care clinic is preparing to test a client for accommodation, Initially, the nurse should ask the client to take which action? 1. Focus on a close object 2. Focus on a distance object 3. Close 1 eye and read letters on a chart 4. Raise 1 finger when the sound is heard

2. Focus on a distance object pupils will dilate

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve) Which technique should the nurse implement to test the motor function of this nerve? 1. Ask the client to puff out the cheeks 2. Separate the client's jaw by pushing down on the chin 3. Place small amount of sugar on the client's tongue and ask him or her to identify the taste 4. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin

2. Separate the client's jaw by pushing down on the chin 4- spinal accessory 1, 3- facial nerve

The nurse is testing the extra ocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1. Test corneal reflexes 2. Test 6 cardinal positions of gaze 3. Test visual acuity, using Snellen eye chart 4. Test sensory function by asking client to close the eyes and then lightly touching the forehead, cheeks, chin

2. Test 6 cardinal positions of gaze

A client diagnosed with conductive hearing loss (physical obstruction) asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1. A deficit in the cochlea 2. A deficit in cranial nerve VIII 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex

3. A physical obstruction to the transmission of sound waves

Skin Melanoma Assessment

ABCDE Assymetry Border Color Diameter

scorbutic gums

Deficiency of vitamin C. Gums are swollen, ulcerated and bleeding due to vitamin-C induced defects in oral epithelial basement membrane and periodontal collagen fiber synthesis.

Identify the heart sounds that can be auscultated at the landmark highlighted below:

Erb's Point, 3rd intercostal space left side

barrel chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema. 1:1 AP transverse

cheilosis

a disorder of the lips characterized by crack-like sores at the corners of the mouth

migraine headache

a headache characterized by throbbing pain on one side of the head

presbycusis

age related hearing loss

cranial nerve xi

ask patient to shrug shoulders

Impetigo

bacterial skin infection characterized by isolated pustules that become crusted and rupture

VIII

hearing

Presbyopia

impairment of vision as a result of old age

Bronchial lung sounds

inspiration < expiration high pitched loud

vesicular

inspiration > expiration soft sound

Bronchovesicular

inspiration= expiration. moderate pitch

confluent

lesions run together

Zosteriform

linear shape of skin lesion along a nerve route

apex of heart

lower tip of the heart

Inspect Palpate Percuss Auscultate

order

Hyperthyroidism

overactive thyroid condition (goiter, exophthalmus, fatigue, weight loss, muscle cramp, tachycardia, heat intolerance)

cluster headache

pain is in and around one eye

Tension headache

pain is like a band squeezing the head

pallor

paleness (anemia)

fremitus

palpable vibration

pustule

papule containing pus

papule

pimple

Magenta tongue

riboflavin deficiency

primary vs secondary lesions

secondary are crusts

Cranial Nerve VII: Facial

smile

otitis externa

swimmers ear

cranial nerve ix and x

tell patient to say ahhh

Rinne test

test for conductive hearing loss

Weber test

test for sensorineural hearing loss

Bronchophony

the spoken voice sound heard through the stethoscope, which sounds soft, muffled, and indistinct over normal lung tissue