Test 2

A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor. Which of the following findings should the nurse expect on performing pectoriloquy?

"1-2-3" is heard clearly

The nurse is conducting the health interview of an adult client who has sought care because of a "wicked cough" leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask?

"How long have you been experiencing your cough?"

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

"You have a conductive hearing loss."

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

30/20

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min

The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve?

Accessory (XI)

An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is 117 beats/min, respirations 36 breaths/min, blood pressure 110/64, and oxygen saturation 82%. What is the first nursing action?

Administer oxygen

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?

Air passing through constricted passageways

The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung is where?

Anterior

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

Ask the client to remove the glasses before testing.

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

Ask the client to say "aaah"

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

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

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

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

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?

Auscultate the client's thyroid

Which of the following would be best for a nurse to use when assessing for fremitus in a client?

Ball of hand

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?

Bradypnea

Which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia?

Bronchial

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document this as which of the following?

Bronchial breath sounds

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern?

Cheyne-Stokes

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following?

Chronic obstructive pulmonary disease

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

Compressing the arteries bilaterally

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

Conductive hearing loss in the right ear

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following?

Consensual response

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

Cranial nerve VII

Which of the following would the nurse assess in a client with severe upper respiratory pneumonia?

Crepitus on palpation

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

Document this as an expected assessment finding

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Dyspnea

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?

Emphysema

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

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

When percussing the scapula of a client, what would the nurse expect to hear?

Flatness

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?

Fremitus

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?

Have the client cough and then listen again

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?

Have the client cough, then listen again

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process?

Heart failure

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

History of allergies

A nurse inspects the anterior thorax of a client with emphysema. Which change in the thorax should the nurse recognize as normal for this client?

Horizontal position to the ribs with a costal angle of greater than 90 degrees

A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following?

Hyperresonance

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Listen at each site for at least one complete respiratory cycle

Which of the following would be most important for the nurse to remember when auscultating the thorax?

Listen at each site for at least one complete respiratory cycle

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

Normal findings for client's age

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

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

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

Percussion

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

Resonance

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

Rinne

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?

Softly repeat the words "one-two-three"

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?

Softly repeat the words "one-two-three."

A client is diagnosed with bronchitis. Which of the following would the nurse hear on auscultation?

Sonorous wheezes

An adult client has been diagnosed with bronchitis. What would the nurse most likely hear on auscultation?

Sonorous wheezes

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

Stridor

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

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

When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse?

The lung has become airless

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

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

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

Weber

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

Whisper test

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

acute bacterial sinusitis

The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by

asking the client to exhale forcefully and hold his breath

What characteristic nail color should the nurse recognize as an indication of hypoxia?

cyanotic

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should...

position the client 609.6 cm (20 ft) away from the chart