Focused assessment 3
Asking the client to shrug his or her shoulders against resistance would test cranial nerve XI which is...
accessory nerve
A nurse is performing a skin assessment and observes symmetrical patchy, milky white spots bilaterally. The nurse interprets these lesions as suggesting which of the following? a. Anemia b. Vitiligo c.Albinism d.Venous stasis
b
When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts? a.actual measurements in centimeters b.symmetry (comparison of bilateral body parts) c.Indications of general health status d.vital signs of all extremities (arms and legs)
b
Which of the following can a nurse assess by palpation? a.heart sounds, lung sounds, blood pressure b.temperature, turgor, moisture c.vision, hearing, cranial nerves d.tissue density, gait, reflexes
b
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called a.inflammation b.Arthritis c.Crepitus d.Fremitus
c
A nurse uses observation to examine a patient's skin. Which patient would the nurse document as having cyanosis? a. A patient who presents with redness in the facial area b.A patient whose skin has a yellowish tint c.A patient whose skin is a dusky, bluish color d.A patient whose skin is pale
c
How would a nurse assess a patient for pupillary accommodation? a.Using an ophthalmoscope, check the red reflex. b.Ask the patient to focus on a finger and move the patient's eyes through the six cardinal positions of gaze. c.Ask the patient to focus on an object as it is brought closer to the nose. d.Ask the patient to read the smallest possible line of letters on the Snellen chart.
c
A nurse performing an integumentary inspection on a patient gently pinches the skin under the clavicle. This nurse is assessing: a.Skin texture b.Skin moisture c.Skin turgor d.Skin vascularity
c (normally checks for dehydration)
A client had a cerebrovascular accident yesterday and is currently comatose. What type of scale should the nurse use to weigh the patient? a.Bathroom scale b.Large floor scale c.Chair scale d.Bed scale
d
The father of a neonate observes that the neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. How should the nurse should interpret this finding? a.stepping reflex b.plantar grasp reflex c.Galant reflex d.Babinski's sign
d
A nurse performs an integumentary assessment of a patient and documents the following: 5/27/12: Examined skin of Mr. Williams. Patient is a white, 56-year-old male who reports a history of emphysema. Skin coloring is bluish gray. What is the term for this change in skin color? a.Jaundice b.Erythema c.Pallor d.Cyanosis
d (Cyanosis is a bluish or grayish tinge caused by inadequate oxygenation.)
What is pallor?
paleness
The client?s pupillary reaction to light would test cranial nerve....
(oculomotor nerve). Cranial nerve III
Smell reception would test cranial nerve...
(olfactory nerve). cranial nerve I
Definition of spastic
A state of increased tone of a muscle (and an increase in the deep tendon reflexes).
What does the glossopharyngeal nerve do?
It receives general somatic sensory fibers (ventral trigeminothalamic tract) from the tonsils, the pharynx,
What is albinism?
Medical condition defined by an absence of melanin pigment
What Is erythema?
Skin redness can have causes that aren't due to underlying disease.
definition of Atonic
Without normal muscle tone or strength. An atonic seizure is one in which the person suddenly loses muscle tone and strength; the person cannot sit or stand upright and, unless supported, falls down.
A nurse asks a patient to raise her eyebrows, smile and show her teeth, and puff out her cheeks. This nurse is most likely assessing which cranial nerve? a.Facial (VII) b.Vagus (X) c.Hypoglossal (XII) d.Accessory (XI)
a
A nurse has explained her intention to conduct Weber's test and Rinne's test. Which of the following pieces of equipment will the nurse require? a.Tuning fork b.Snellen chart c.Otoscope d.Ophthalmoscope
a
A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision? a.Snellen chart b.stethoscope c.ophthalmoscope d.otoscope
a
The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? a.Palpation b.Inspection c.Percussion d.Auscultation
a
The nurse is conducting an assessment of a 74-year-old patient's integumentary system. Which of the following findings should the nurse document as an anomaly that may warrant follow-up? a.The patient states that a mole on his forehead has become larger in recent months. b.Decreased skin turgor is evident when the skin is folded and then released. c.Small, round, red spots are present on the patient's forearms bilaterally. d.There are some raised, brown areas on the backs of the patient's hands.
a
The nurse observes the client as he walks into the room. What information will this provide the nurse? a.Information regarding the client's gait b.Information regarding the client's personality c.Information regarding the client's psychosocial status d.Information on the rate of recovery from surgery
a
The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? a.Palpation b.Percussion c.Auscultation d.Inspection
a
The nurse would include which of the following in a neurological assessment? a. Ask the client to plantar flex the toes. b. Capillary refill of the great toe. c. Palpate the dorsalis pedis pulse. d. Inspect the foot for edema.
a
When assessing the glossopharyngeal nerve, it is most important for the nurse to implement which intervention? a. Note the client?s ability to swallow b.Ask the client to shrug his or her shoulders against resistance T b. best the client?s nostrils for smell reception c. Assess the client?s pupillary reaction to light
a
Which of the following describes a muscle that is limp and without tone? a. Flaccid b. Spastic c. Atonic d. Paralysis
a
What is cyanosis?
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
What is anemia?
a decrease in the oxygen-carrying ability of the blood