Foundations Chapter 31 Health Assessment and Physical Examination

2, 4, 5 The Glasgow Coma Scale (GCS) allows evaluation of a patient's neurological status over time on a numerical scale. The higher the score, the better the patient's neurological function. The categories for scoring GCS include opening of eyes, best verbal response, and best motor response. A patient who is fully conscious, responds to questions quickly, and expresses ideas logically would have a high GCS. The GCS cannot be used to assess appearance or mood swings.

A 25-year-old patient has sustained a head injury and is brought to the emergency department. The nurse is assessing the patient's level of consciousness using the Glasgow Coma Scale (GCS). Which categories are scored in the GCS? Select all that apply. 1 Appearance 2 Eyes open 3 Mood swings 4 Best verbal response 5 Best motor response

2, 3, 4, 5 The screening for uterine cancer starts 3 years after having vaginal intercourse or at the age of 21 years. The screening for breast cancer starts from the age of 20 years. The screening for ovarian cancer starts from 18 years of age or after becoming sexually active. The screening for endometrial cancer starts 3 years after having vaginal intercourse or at the age of 21 years. The screening for colorectal cancer is usually after 50 years of age.

A 30-year-old female patient visits a clinic for a regular checkup. Which cancer screenings should the patient undergo? Select all that apply. 1 Colorectal cancer 2 Uterine cancer 3 Breast cancer 4 Ovarian cancer 5 Endometrial cancer

2, 3, 5 Delirium is defined as an acute disturbance of consciousness and change in cognition. A patient with delirium is usually disoriented to time, place, and person due to cognitive impairment. The patient may not be able to name nearby objects. Delirium is usually not caused by preexisting dementia but has a precipitating factor such as surgery or certain drugs. Recent memory may be lost, and the patient may not be able to remember incidents that happened the day before. Perceptual disturbances are common in delirium and include misinterpretations, delusions, or visual and auditory hallucinations

A 78-year-old patient has confused speech and tells the attending nurse that aliens are waking him up when he is trying to sleep. The nurse assesses the level of consciousness in the patient and suspects delirium. What are the criteria to diagnose delirium? Select all that apply. 1 No loss of recent memory 2 Disorientation to time, place, or person 3 Impaired ability to name objects 4 No perceptual disturbances 5 Acute onset, not caused by preexisting dementia

4 The lithotomy position provides maximum exposure of female genitalia and facilitates the insertion of a vaginal speculum. While assessing the heart, the patient should be asked to assume the lateral recumbent position. While assessing the rectum and vagina, the patient should be asked to assume the Sims' position. While assessing the musculoskeletal system, the patient should be asked to assume a prone position.

A nurse instructs a patient to assume the lithotomy position. For what does the nurse plan to assess? 1 Heart 2 Rectum and vagina 3 Musculoskeletal system 4 Genitalia and genital tract

1 Skin turgor and elasticity should be checked by grasping the skin with fingertips, not by using finger pads. Skin texture and thickness should be assessed by using the palmar surface of the hand. Temperature should be checked by using the dorsum of the hand or fingers.

A nurse is examining a patient's skin using palpation. Which action made by the nurse needs correction? 1 Checking the patient's skin turgor and elasticity by using finger pads 2 Checking the patient's skin texture using the palmar surface of the hand 3 Checking the patient's skin thickness with the palmar surface of the hand 4 Checking the patient's temperature using the dorsum of the hand or fingers

2 While assessing the rectum, the nurse should ask the patient to assume knee-chest position, because this position provides maximum exposure of the rectal area. While assessing the extension of hip joint, skin, and buttocks, the patient should be asked to assume prone position. While assessing the abdomen, the patient should be asked to assume dorsal recumbent position. While assessing the heart, the patient should be asked to assume lateral recumbent position.

A nurse is preparing to examine a patient's rectum. Which position should the nurse ask the patient to assume? 1 Prone 2 Knee-chest 3 Dorsal recumbent 4 Lateral recumbent

1, 3 While examining a patient who is allergic to latex, the nurse should refrain from using rubber aprons and disposable syringes; instead, the nurse should use cloth-covered aprons and glass syringes. Neoprene gloves, covered blood pressure cuffs, and a stethoscope with covered tubing are safe to use while assessing patients who are allergic to latex.

A nurse is preparing to perform a physical examination of a patient who is allergic to latex. Which equipment should the nurse avoid using? Select all that apply. 1 Rubber aprons 2 Neoprene gloves 3 Disposable syringes 4 Covered blood pressure cuffs 5 Stethoscope with covered tubing

3 The Glasgow Coma Scale requires a nurse to use three score ranges based on the categories of eye opening, verbal responsiveness, and motor response. In this case, the nurse's assessment reflects eye and verbal response only. No motor activity, such as the ability of the patient to follow commands or spontaneous movement by the patient, is noted.

A patient found unresponsive now opens eyes when spoken to, gives correct answers to simple questions when asked, and usually sleeps when left unattended. Which category of the Glasgow Coma Scale has the nurse assessed? 1 Eye opening and motor activity 2 Motor activity and motor response 3 Eye opening and best verbal response 4 Best verbal response and best motor response

2 Aminoglycoside is an ototoxic drug. High doses of aminoglycosides may cause injury to the auditory nerve, which leads to ototoxicity. Presbyopia, malignancy, and dysrhythmias are not caused by a high dose of aminoglycosides. Presbyopia is impaired near vision that occurs in elderly people. Malignancy refers to cancer cells that rapidly spread to other tissues of the body. Dysrhythmia refers to the alteration in the heart's conduction system.

A patient has been prescribed a high dose of aminoglycoside. As a result, which condition will the patient most likely experience? 1 Presbyopia 2 Ototoxicity 3 Malignancy 4 Dysrhythmia

4, 3, 1, 2 The nurse must receive consent before performing any procedure on a patient. It is recommended that the nurse take a clinical history and do the physical examination of the abdomen afterward. During the abdominal assessment, auscultation of the abdomen should be done before palpation because manipulation of the abdomen alters the frequency and intensity of bowel sounds. The best time to auscultate is between meals. Absent sounds indicate a lack of peristalsis, possibly the result of bowel obstruction (late stage), paralytic ileus, or peritonitis.

A patient is admitted to the hospital with an intestinal obstruction. The surgical nurse records the vitals and starts to examine the patient's abdomen. In which order should the nurse conduct the examination? Arrange the activities in the correct order. 1. Auscultation of abdomen 2. Palpation of abdomen 3. Inspection of abdomen 4. Consent from the patient

4, 5 The nurse should use the entire palmar surface of the hand or the palmar surface of the fingers to palpate the liver. These surfaces of the hand are more sensitive and are used to determine the size, shape, tenderness, and absence of masses in the liver. The dorsum of the hand is used to assess temperature. The ulnar surface of the entire hand is used to assess fremitus. The pads of the fingers are used to assess the glands.

A patient is admitted to the hospital with cirrhosis of the liver. The nurse performs a physical assessment of the patient. Which area of the hand should the nurse use when palpating the liver? Select all that apply. 1 Dorsum of the hand 2 Ulnar surface of the entire hand 3 Pads of fingers 4 Entire palmar surface of the hand 5 Palmar surface of the fingers

4, 5 The nurse should use the entire palmar surface of the hand or the palmar surface of the fingers to palpate the liver. These surfaces of the hand are more sensitive and are used to determine the size, shape, tenderness, and absence of masses in the liver. The dorsum of the hand is used to assess temperature. The ulnar surface of the entire hand is used to assess fremitus. The pads of the fingers are used to assess the glands.

A patient is admitted to the hospital with cirrhosis of the liver. The patient has a history of alcohol abuse. Which questions should the nurse ask the patient according to the CAGE questionnaire to assess substance abuse? Select all that apply. 1 Does the patient feel guilty about the habit and addiction? 2 Is the patient annoyed by those who criticize the habit? 3 Does the substance excite the patient to commit crimes? 4 Has the patient ever tried to cut down on the substance to which the patient is addicted? 5 Does the patient experience delusions of grandeur on having the drink or substance to which the patient is addicted?

2, 3, 4 The parameters tested in the Glasgow Coma Scale (GCS) include opening of eyes in response to commands, verbal responses, and motor response to commands. A fully conscious patient responds to questions quickly and expresses ideas logically. The lateralization of sound is assessed by Weber's test. Air and bone conduction in the ears is assessed by the Rinne test.

A patient is brought to the emergency room following a motor-vehicle accident. The nurse assesses the patient's levels of consciousness using a Glasgow Coma Scale (GCS). Which parameters does this test evaluate? 1 Lateralization of sound 2 Opening of eyes 3 Verbal response 4 Motor response 5 Air and bone conduction

1 Osteopenia is characterized by low bone mass of the hip. An increased lumbar curvature is known as lordosis. Osteoporosis is a systemic skeletal condition with decreased bone mass and deterioration of bone tissue. Kyphosis is an exaggeration of the posterior curvature of the thoracic spine.

A patient is diagnosed with osteopenia. What does the nurse expect to find in this patient? 1 Low bone mass of the hip 2 Increased lumbar curvature 3 Deterioration of bone tissue 4 Exaggeration of the posterior curvature of the thoracic spine

2 To keep a physical examination well organized, the nurse should carry out painful procedures at the end of the examination. If the patient becomes exhausted during the examination, the nurse should not stop the assessment; instead, the nurse should allow the patient to rest between the assessments. The nurse should document quick notes during the assessment and complete larger notes at the end of the examination; this will help avoid delays and confusion. The nurse should document assessments in specific terms in the electronic or paper record.

A registered nurse is providing tips to a student nurse to help keep a physical examination well organized. Which statement should be included in the teaching? 1 "If the patient becomes exhausted, stop the assessment." 2 "Carry out painful procedures at the end of the examination." 3 "Complete all documentations at the end of the examination." 4 "Document assessments in specific terms only in the electronic record."

2 While assessing a patient's rectum and vagina, the nurse should ask the patient to assume Sims' position, not prone position, because this position improves the exposure of rectal area. While assessing a patient's heart, the nurse should ask the patient to assume lateral recumbent position, because this position facilitates easy detection of murmurs. While assessing a patient's abdomen, the nurse should ask the patient to assume dorsal recumbent position, because this position promotes relaxation of abdominal muscles. While assessing a patient's musculoskeletal system, the nurse should ask the patient to assume prone position, because this position provides easy access to the extension of hip joint, skin, and buttocks.

A registered nurse is teaching a group of nursing students about different positions that patients should assume while examining various areas of the body. Which statement if made by a student nurse indicates a need for further teaching? 1 "While assessing a patient's heart, I'll ask the patient to assume lateral recumbent position." 2 "While assessing a patient's rectum and vagina, I'll ask the patient to assume prone position." 3 "While assessing a patient's abdomen, I'll ask the patient to assume dorsal recumbent position." 4 "While assessing a patient's musculoskeletal system, I'll ask the patient to assume prone position."

4 While examining a child, the nurse should ask open-ended questions to the child's parents to obtain more information. The nurse should first complete a visual examination while talking to the child, before touching the child; this will help gain the child's trust. The nurse should address the child's parent as Ms., Mr., or Mrs. and call the child by his or her first name.

A registered nurse provides tips to nursing students to help them in data collection. Which action if made by a student nurse while examining a child indicates a need for further teaching? 1 Completing a visual examination first 2 Addressing the child's parent as "Ms." 3 Calling the child by his or her first name 4 Asking closed-ended questions to the child's parents

4 According to the American Cancer Society guidelines, the recommendation for performing a colonoscopy in a patient over 50 years old is every 10 years. It is recommended that fecal occult blood or fecal immunochemical tests be performed annually. Stool DNA test should be performed every 3 years. Flexible sigmoidoscopy and double-contrast barium enemas should be performed every 5 years.

According to the American Cancer Society guidelines, for a 52-year-old patient, how often should a colonoscopy be performed? 1 1 year 2 3 years 3 5 years 4 10 years

2 If a patient's oral cavity or breath has a sweet, fruity ketone smell, the patient is indicating for diabetic acidosis. If a patient's oral cavity or breath has a halitosis smell, the patient might be having poor dental and oral hygiene or gum disease. If a patient's draining wound has a sweet, heavy, thick odor, the patient might be having a Pseudomonas (bacterial) infection. If a patient's rectal area has a feces odor, the patient might be experiencing fecal incontinence.

After inspecting four patients, a nurse documents the findings in a chart. Which patient does the nurse anticipate has diabetic acidosis? 1 Patient A 2 Patient B 3 Patient C 4 Patient D

2, 3, 4, 5 A victim of intimate partner violence may have trouble swallowing, burns from cigarettes, difficulty sitting or walking, and strangulation marks on the neck. Older adults who are victims of abuse may have bed sores.

After performing a physical examination, a nurse suspects that the patient is a victim of intimate partner violence. Which findings support the nurse's suspicion? Select all that apply. 1 The patient has bed sores. 2 The patient has trouble swallowing. 3 The patient has burns from cigarettes. 4 The patient has difficulty sitting or walking. 5 The patient has strangulation marks on the neck.

1 While examining a patient's body using palpation, the nurse should palpate tender areas at the end of the examination. The nurse should ask the patient to take slow, deep breath; this will help promote relaxation. The nurse should ask the patient to point to more sensitive areas; this will help detect tender areas of the body. The nurse should warm his or her hands before touching the patient to make the patient comfortable.

After teaching a student nurse about palpation, a registered nurse is observing the student nurse while palpating a patient's body parts. Which action made by the student nurse needs correction? 1 The student nurse palpates tender areas first. 2 The student nurse asks the patient to take slow, deep breath. 3 The student nurse asks the patient to point to more sensitive areas. 4 The student nurse warms his or her hands before touching the patient.

1, 2, 4 Adhesive tape, rubber Foley catheters, and rubber-coated plungers should be avoided for patients with latex allergies because they can trigger an allergic or anaphylactic response. Latex is not found in a standard toothbrush or toothpaste, nor is it found in a transparent wound dressing; thus, it is not necessary to question the patient about a latex allergy in these situations.

As the nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? Select all that apply. 1 Applying adhesive tape to anchor a nasogastric tube 2 Inserting a rubber Foley catheter into the patient's bladder 3 Providing oral hygiene using a standard toothbrush and toothpaste 4 Giving an injection using plastic syringes with rubber-coated plungers 5 Applying a transparent wound dressing

1 When the blood passes through the narrowed section, it creates turbulence that causes a blowing or swishing sound, called a bruit. A thrill is a continuous palpable sensation that resembles the purring of a cat. When the sinus sends impulses along the vagus nerve, the stimulation causes a reflex drop in heart rate and blood pressure, which causes syncope or circulatory arrest. Murmurs are sustained as swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase.

During a vascular system assessment the nurse finds a blowing sound in the carotid artery of the patient. What does the nurse document in the medical report? 1 Bruit 2 Thrill 3 Syncope 4 Murmurs

3 To identify the risk of impaired venous return, the nurse asks the patient about whether he or she wears tight-fitting hosiery. The nurse asks about heart risk factors (e.g., smoking, exercise, nutritional problems) to refine the previous medical history information and help determine if the patient is predisposed to vascular disease. To assess for possible musculoskeletal problems, the nurse should ask the patient whether he or she experiences leg pain. To assess for vascular and circulatory disorders, the nurse should review the patient's medical history for heart disease.

During an assessment, the nurse asks a patient if he or she wears tight-fitting hosiery. What could be the reason behind this question by the nurse? 1 To identify possible vascular disease 2 To determine any musculoskeletal problems 3 To identify the risk of impaired venous return 4 To determine the presence of vascular and circulatory disorders

4 The nurse is performing auscultation. Auscultation involves listening to the sounds of the body to detect abnormalities. Palpation is used to make judgments about abnormal and normal findings of the skin or underlying tissue, muscle, and bones. In the inspection technique, the nurse observes the size, shape, color, symmetry, position, and abnormality of various body parts. Percussion involves tapping the skin with the fingertips to vibrate the underlying tissues and organs.

During the physical examination of a patient, the nurse listens to the heart sounds to detect variations from normal. Which physical examination technique is the nurse performing? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

2 Flexible sigmoidoscopy is used as a screening measure for rectal cancer. Annual pelvic examinations should be used as a screening measure for the early detection of ovarian cancer. The screening measures for breast cancer include yearly mammograms. The screening measures for testicular cancer include monthly testicular self-examinations.

Flexible sigmoidoscopy is used to screen for which condition? 1 Breast cancer 2 Rectal cancer 3 Ovarian cancer 4 Testicular cancer

2 Clubbing of the fingers is directly associated with chronic lack of oxygen to the capillary beds of the fingers. Callus formation on heels, graying hair, and swollen toes and ankles are not associated with respiratory difficulty. A callus may form due to thickening of the epidermis. Graying hair is an age-related change. Swollen toes and ankles may or may not be due to fluid retention or heart failure.

In addition to cyanotic lips and nail beds, nasal flaring, and pursed lips, which sign would directly indicate that a patient is suffering from cardiac or pulmonary difficulty? 1 Graying of the hair 2 Clubbing of the fingers 3 Swollen toes and ankles 4 Callus formation on heels

1 The rectum and anus of a nonambulatory patient are examined using the Sims' position. The prone position is used to examine the musculoskeletal system. The sitting position is used for examining head and neck, back, posterior thorax, and lungs. The supine position is used to examine head and neck, anterior thorax, and lungs.

In which position are the rectum and anus of a nonambulatory patient examined? 1 Sims' position 2 Prone position 3 Sitting position 4 Supine position

2 Cranial nerve IX is the glossopharyngeal nerve, which is associated with taste and the ability to swallow. To test the functioning of this nerve, the nurse asks the patient to identify a sour or sweet taste on the back of the tongue, and also uses a tongue blade to elicit the gag reflex. Cranial nerve X is the vagus nerve, which is responsible for the sensation of the pharynx, movement of the vocal cords, and parasympathetic innervation to the glands of mucous membranes. Cranial nerve VII is the facial nerve, which is associated with taste and the ability to swallow. To assess the functioning of this nerve, the nurse has the patient identify a salty or sweet taste on the front of the tongue. Cranial nerve VIII is the auditory nerve, responsible for the sensation of hearing. During the neurological examination, the nurse would assess the patient's ability to hear spoken words.

The nurse asks the patient to identify sour or sweet taste on the back of the tongue during a physical assessment. What is the cranial nerve being assessed? 1 X 2 IX 3 VII 4 VIII

3 Pronation is the movement of a body part so that the front, or ventral surface, faces downward. The hand and forearm can be put through this type of motion. Flexion is movement that decreases the angle between two adjoining bones. Extension is movement that increases the angle between two adjoining bones. Both flexion and extension can be observed in the elbow, fingers, and the knee. Supination can be observed in the forearm, but this is the movement of the body part such that front or ventral surface faces upward, not downward.

The nurse asks the patient to move a forearm so that its ventral surface faces downward during a physical examination. Which type of movement is the nurse asking the patient to demonstrate? 1 Flexion 2 Extension 3 Pronation 4 Supination

2 The nurse asks the patient to demonstrate abduction, which is movement of an extremity away from the midline of the body. Flexion is movement decreasing angle between two adjoining bones, such as bending of limb. Adduction is movement of an extremity toward the midline of the body. Hyperextension is movement of a body part beyond its normal resting extended position.

The nurse asks the patient to move the legs away from the midline of the body during a physical assessment. Which range-of-motion position is the nurse asking the patient to demonstrate? 1 Flexion 2 Abduction 3 Adduction 4 Hyperextension

3 The nurse should ask the patient to assume a sitting position. The upright position provides better visualization of the symmetry of the upper body, thorax, and lungs. The Sims' position is used to examine the rectum and vagina. The prone position is used to examine the musculoskeletal system. The supine position is used to examine the head and neck, breasts, axillae, heart, abdomen, extremities, and pulse.

The nurse assesses a patient who presents with a cough. Which position should the nurse instruct the patient to assume for a proper examination? 1 Sims' 2 Prone 3 Sitting 4 Supine

1 An "F" on the Lovett Scale indicates "fair" or grade 3; this is associated with full range of motion with gravity. A slight contractility and no movement are associated with a "T" or "trace" on the Lovett Scale. A passive movement with full range of motion is associated with a "P" or "poor" on the Lovett Scale. A full range of motion against gravity with some resistance is associated with a "G" or "good" on the Lovett Scale.

The nurse gives the patient an F on the Lovett Scale after testing muscle strength. What is the patient's expected muscle function level? 1 Full range of motion with gravity 2 Slight contractility and no movement 3 Passive movement with full range of motion 4 Full range of motion against gravity with some resistance

2, 3, 5 The lithotomy position is the best position for facilitating insertion of a vaginal speculum. It gives maximum exposure of the female genitalia and is useful in gynecological procedures. The patient lies supine and her legs are raised and flexed at the knee. This position doesn't help in detecting murmurs. Murmurs are best heard in the lateral recumbent position. The patient lies laterally with flexion of hip and knee in Sim's position.

The nurse has to position a patient in the lithotomy position. Which statement about the lithotomy position is true? Select all that apply. 1 This position helps in detecting murmurs. 2 This position facilitates insertion of vaginal speculum. 3 This position is adopted for examination of female genitalia. 4 The patient is laid down laterally with flexion of hip and knee. 5 The patient is laid down supine, the legs are raised, and knees flexed.

1, 2 The Glasgow Coma Scale (GCS) measures consciousness on a numerical scale based on eye, motor, and verbal response. For an accurate assessment, the nurse should ensure that the patient is alert enough to follow the instructions provided. The patient may not be able to follow instructions for the test if the patient has a sensory loss such as sight or hearing. It is not necessary to perform the test in front of a family member; it is like a short interview. The test is noninvasive; therefore, informed consent may not be necessary. The nurse can perform the test without the orders of a health care provider.

The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS). Which precautions should the nurse take to ensure that the assessment is accurate? Select all that apply. 1 Ensure the patient is as alert as possible. 2 Monitor sensory losses. 3 Perform tests in front of a family member. 4 Obtain a signed, informed consent from the patient. 5 Obtain the health care provider's approval.

3 To assess the functioning of spinal accessory nerve XI, the nurse should ask the patient to shrug the shoulders and turn the head against passive resistance. The nurse should ask the patient to say "ah" and observe the movement of the palate and the pharynx to test the functioning of the vagus nerve X. To test the functioning of the hypoglossal nerve XII, the nurse should ask the patient to stick out the tongue to midline and move it from side to side. To test the functioning of the olfactory nerve, the nurse should ask the patient to identify different nonirritating aromas such as coffee and vanilla.

The nurse is assessing the functioning of the patient's cranial nerve XI. What would the nurse ask the patient to do to test this nerve? 1 Ask the patient to say "ah." 2 Ask the patient to stick out tongue to midline and move it from side to side. 3 Ask the patient to shrug shoulders and turn head against passive resistance. 4 Ask the patient to identify different, nonirritating aromas such as coffee and vanilla.

1 Assessment of muscle reflexes includes grading response to deep tendon reflexes and cutaneous reflexes. A sluggish response is graded 1+. If there is no response, the grade is 0. An active or expected response is graded 2+. A grade 3+ response is more brisk than expected, and slightly hyperactive. A brisk and hyperactive response with intermittent or transient clonus is graded 4+.

The nurse is assessing the muscle reflexes in a patient and finds that the reflexes are sluggish. What grade should the nurse give the reflexes? Record the answer using a whole number. ____

1 While assessing the sensory function of position in the patient, the nurse grasps a finger and holds it by its sides with the thumb and index finger. Then, the nurse alternates moving the finger up and down, asking the patient to state when the finger is up or down. This process is repeated with the toes. The nurse applies the sharp and blunt ends of a paper clip or a broken cotton applicator to the surface of the patient's skin and notes the areas of numbness or increased sensitivity, while assessing the patient's ability to feel pain. The nurse touches the patient's skin with hot and cold test tubes, asking the patient to identify hot or cold sensations, while assessing the patient's ability to sense temperature. The nurse applies the stem of a vibrating fork to the distal interphalangeal joint of the patient's fingers and the interphalangeal joint of the great toe, the elbow, and the wrist, and has the patient voice when and where the patient feels vibration, while assessing the patient's ability to feel vibration.

The nurse is assessing various sensory nerve functions in a patient. Which method will the nurse use while assessing the patient's proprioception? 1 Moving the patient's finger up or down and asking the patient to state the position of the finger 2 Applying sharp and blunt ends of a paper clip or broken cotton applicator to the surface of the skin 3 Touching the skin with hot and cold test tubes and asking the patient to identify hot or cold sensations 4 Applying the stem of a vibrating fork to the distal interphalangeal joint of the fingers and the interphalangeal joint of the great toe

2 The Snellen chart is a tool to assess the integrity of the optic nerve. In this test, the patient is asked to read the letters in the chart from a specific distance. Weber's and Rinne tests are used for the assessment of auditory functioning. The Glasgow Coma Scale is used to assess level of consciousness.

The nurse is caring for a patient who sustained a cerebral vascular accident (CVA). How should the nurse assess the integrity of the optic nerve in the patient? 1 Perform a Weber's test. 2 Use a Snellen chart. 3 Perform a Rinne test. 4 Use the Glasgow Coma Scale.

30 While performing an examination of the patient's head, the table should be elevated at an angle of 30 degrees. This inclined position is most comfortable for the patient's head and neck and is also suitable for the assessment.

The nurse is examining a patient's head and neck. At what angle should the nurse elevate the head of the examination table so that the patient is comfortable? Record your answer using a whole number. __ degrees

3 The dorsal surface of the hand is used to check body temperature, which gives a relative measurement (high or low) of the body temperature. A thermometer is needed to get the exact measurement of the body temperature. Deep palpation is used to examine the condition of organs such as those in the abdomen. The pads of the fingers are used to check swelling, symmetry, and mobility of glands but are not as reliable in gauging temperature. The palmar surface is used to determine position, texture, size, consistency, masses, fluid, and crepitus.

The nurse is measuring the body temperature of a patient. How can the nurse check a patient's body temperature using a palpation technique? 1 By using deep palpation 2 By using only the pads of the fingers 3 By using the dorsal surface of the hand 4 By using the palmar surface of the hand

4 A Mini-Mental State Examination (MMSE) helps to assess orientation and cognitive function of the patient by asking specific questions. The maximum score is 30. A score of 21 or less indicates a cognitive impairment. The MMSE is not useful to assess alcohol content of blood, because the alcohol content can be tested by laboratory tests. Sensory and motor deficits can be assessed by testing reflexes. The risk of development of seizures cannot be tested by MMSE.

The nurse is performing a Mini-Mental State Examination (MMSE) on an alcoholic patient. Which parameter can be assessed by the MMSE? 1 Alcohol content of blood 2 Sensory and motor deficits 3 Risk of development of seizures 4 Orientation and cognitive function

1, 2 The Mini-Mental State Examination (MMSE) is an instrument developed by Folstein et al. It provides information regarding a patient's orientation and cognitive function. It cannot provide information regarding risk of cancer, seizures, and alcohol blood level.

The nurse is performing a Mini-Mental State Examination (MMSE) on an intoxicated patient. Which parameters will the nurse evaluate in the patient? Select all that apply. 1 Orientation 2 Cognitive registration 3 Risk of developing cancer 4 Risk of developing seizures 5 Levels of alcohol in the blood

7 According to the Glasgow Coma Scale, not opening the eyes is given a score of 1. If the best verbal response is uttering incomprehensible sounds, the score given is 2. If the best motor response is flexion withdrawal, the score given is 4. The patient's total score on the Glasgow Coma Scale is 1 + 2 + 4 = 7.

The nurse is performing a neurological assessment of a patient in the emergency department. The patient does not open the eyes, utters incomprehensible sounds, and the best motor response is flexion withdrawal. Calculate the patient's score on the Glasgow Coma Scale. Record your answer using a whole number. ___

3 Diminished or absent pulses occur in arterial insufficiency because there is inadequate blood supply to the peripheral circulation. There is little to no edema in arterial insufficiency, whereas marked edema is seen in venous insufficiency. There may be local coolness on the affected area in arterial insufficiency. The skin is pale but it worsens on elevation of the extremity in arterial insufficiency.

The nurse is performing a physical examination of a patient. Which finding would favor the diagnosis of arterial insufficiency? 1 Marked edema 2 Rise in local temperature 3 Diminished or absent pulses 4 Pale skin color that improves on elevation of extremity

2 The apex of the heart touches the fourth to fifth intercostal space just medial to the left midclavicular line; the apical impulse is palpated best in this anatomical region. The second intercostal space on the right side is the aortic area. The fourth or fifth intercostal space along the sternum is the tricuspid area. The second pulmonic area is at the left sternal border to the third intercostal space.

The nurse is performing a physical examination on a patient. Where should the nurse palpate for the apical impulse? 1 At the second intercostal space on the right side 2 At the fourth intercostal space just medial to the left midclavicular line 3 At the fourth or fifth intercostal space along the sternum 4 At the left sternal border to the third intercostal space

1, 4 A normal dorsalis pedis indicates good arterial blood flow to the lower extremities. Chronic loss of arterial flow results in a lack of hair growth and the appearance of shiny tissue. The dorsalis pedis is located along the top of the foot between the great toe and first toe. When there is poor arterial flow, the skin will be cool.

The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? Select all that apply. 1 A normal pulse on the top of the foot indicates adequate blood flow to the foot. 2 To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee. 3 When there is poor arterial blood flow, the leg is generally warm to the touch. 4 Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. 5 Long periods of sitting or standing may help increase blood flow

1 Homans' sign is no longer a reliable indicator of phlebitis, because it is present in other conditions. The nurse should assess for unilateral edema, because it is one of the manifestations for phlebitis. The nurse should inspect the calves for localized redness and swelling of the veins, because it is an indication for phlebitis. The nurse should gently palpate the calf muscle to reveal warmth.

The registered nurse is teaching a nursing student about the assessment of phlebitis. Which statement if made by the nursing student indicates the need for further teaching? 1 "I should assess for Homan's signs." 2 "I should assess for unilateral edema." 3 "I should inspect the calves for localized redness." 4 "I should gently palpate the calf muscle to reveal warmth."

1 The nurse should not palpate the carotid artery vigorously, because the carotid sinus is located at the bifurcation of the common carotid arteries in the upper third of the neck. The nurse should examine one carotid artery at a time. The nurse should begin the inspection of the neck by checking for pulsation of the carotid artery. The nurse should make the patient lie supine with the head elevated to 31 degrees.

The registered nurse is teaching the nursing student about examining carotid arteries. Which statement if made by the nursing student indicates a need for further teaching? 1 "I should palpate the carotid artery vigorously." 2 "I should examine one carotid artery at a time." 3 "I should inspect the neck for pulsation of the carotid artery." 4 "I should make the patient lie supine with the head elevated."

4 The student nurse lists correct information about the glossopharyngeal nerve. The glossopharyngeal nerve has both sensory and motor functions. Its motor function is controlling the ability to swallow. To assess this, the nurse would use the tongue blade to elicit the gag reflex. The facial nerve has both sensory and motor functions. Its functions are controlling facial expressions and the sense of taste. The nurse assesses these functions by looking for asymmetry in facial expressions, and having the patient identify salty or sweet tastes on the front of the tongue. The nurse would measure sensation of light pain and touch across the skin of the face while assessing the trigeminal nerve. The nurse also assesses the function of the trigeminal nerve by palpating the temples as the patient clenches the teeth. However, this nerve has both sensory and motor functions; it acts as a sensory nerve to the skin of the face and as a motor nerve to the muscles of the jaw. The hypoglossal nerve has only motor function. However, its function is controlling the position of the tongue. It is assessed by asking the patient to stick out the tongue to midline and move it from side to side.

The student nurse prepares a chart listing the type, function, and the method of assessment of the trigeminal, facial, and glossopharyngeal nerves. Which nerve has the student described correctly? 1 Facial 2 Trigeminal 3 Hypoglossal 4 Glossopharyngeal

4 Opening the eyes in response to pain is associated with a score of 2. No response in terms of opening the eyes is given a score of 1. Spontaneously opening the eyes is given a score of 4. Opening the eyes in response to speech is given a score of 3.

The victim of an accident is bought to the emergency department of a hospital. The nurse documents a score of 2 for Eye Opening Response on the Glasgow Coma Scale. Which response has the nurse observed in the patient? 1 The patient has not opened the eyes at all. 2 The patient has spontaneously opened the eyes. 3 The patient has opened the eyes when spoken to. 4 The patient has opened the eyes in response to pain.

3 The Glasgow Coma Scale ranges from the lowest score of 3 to the highest score of 15. A score of 3 would indicate that the patient is in the deepest coma. A score of 0 or 1 is incorrect because these numbers are lower than the number at which the scale begins measurement. A score of 10 would indicate higher cognitive functioning.

Using the Glasgow Coma Scale, what would be the score of a patient who is in a deep coma? 1. 0 2. 1 3. 3 4. 10

1 During psychological preparation of a patient before a physical examination, the nurse should not exhibit a quiet, formal behavior; this may stop the patient from communicating further. The nurse should thoroughly explain the purpose of the assessment to make the patient understand what to expect and how to cooperate. The nurse should also encourage the patient to comment if he or she feels any discomfort during the examination. Behaving in a very casual way might make the patient doubt the nurse's capability.

Which action made by a nurse during psychological preparation of a patient before a physical examination may limit the patient's communication ability? 1 Exhibiting a quiet, formal behavior 2 Thoroughly explaining the purpose of the assessment 3 Asking the patient to comment if he or she feels any discomfort 4 Behaving in a very casual way to make the patient comfortable

2, 3, 4 The functions of the oculomotor nerve include opening the eye, extraocular eye movements, and pupil constriction and dilation. The optic nerve is associated with visual acuity. The abducens nerve is responsible for the lateral movement of eyeballs.

Which are the functions of the oculomotor nerve? Select all that apply. 1 Visual acuity 2 Opening the eye 3 Extraocular eye movements 4 Pupil constriction and dilation 5 Lateral movement of eyeball

2 The ulnar artery is located on the medial of the wrist. Therefore, the nurse is palpating the ulnar pulse. This pulse should be palpated using two or three fingertips. The ulnar pulse is palpated only while evaluating the arterial insufficiency to the hand. The tibial pulse is located in the lower limb. The radial pulse is located along the radial side of the forearm at the wrist. The brachial pulse is located along the medial side of the extended arm.

Which artery is the nurse using for palpation in the given image? 1 Tibial 2 Ulnar 3 Radial 4 Brachial

3 Pictured here is the knee-chest position, a position the nurse may use to assess the rectum. Lateral recumbent position is used to examine the heart. The vagina is examined using the Sims' position. Prone position is used to examine the musculoskeletal system.

Which assessment can the nurse perform using the position illustrated here? 1 Heart 2 Vagina 3 Rectum 4 Musculoskeletal system

1 The olfactory nerve has only sensory function. The trigeminal and glossopharyngeal nerves have both sensory and motor functions. The oculomotor nerve has only motor function.

Which cranial nerve has only sensory function? 1 Olfactory 2 Trigeminal 3 Oculomotor 4 Glossopharyngeal

2 The olfactory cranial nerve is responsible for the sense of smell. The vagus nerve is responsible for the sensation of the pharynx. The trochlear nerve is responsible for downward and inward eye movements. The trigeminal nerve is responsible for the sensory nerve innervation of the face.

Which cranial nerve is responsible for the sense of smell? 1 Vagus 2 Olfactory 3 Trochlear 4 Trigeminal

2, 3 The facial and the vagus nerves have both sensory and motor functions. The optic nerve has only sensory function. The trochlear and hypoglossal nerves have only motor functions.

Which cranial nerves have both sensory and motor functions? Select all that apply. 1 Optic 2 Facial 3 Vagus 4 Trochlear 5 Hypoglossal

3 To assess the patient's ability to sense temperature changes, the nurse uses two test tubes, one filled with hot water and another with cold water. The nurse touches the patient's skin with these tubes and asks the patient to identify hot or cold sensation. A tuning fork is used while assessing the patient's ability to feel vibrations. Two ends of paper clips are used while assessing the patient's ability to use two-point discrimination. The end of a paper clip or the wooden end of a cotton applicator is used for assessing the patient's ability to sense pain.

Which equipment does the nurse use to assess the sensory nerve function that controls the patient's ability to sense temperature changes? 1 Tuning fork 2 Two ends of paper clips 3 Two test tubes filled with water 4 Wooden end of cotton applicator

2, 4, 5 Extension involves movement that increases the angle between two adjoining bones. The knee, finger, and elbow can be put through this range of motion. The hip can be put through internal and external rotations, which are associated with rotation of joint inward and outward, respectively. The head can be put through hyperextension, which is associated with the movement of the body part beyond its normal resting extended position.

Which joints can the nurse put through the extension range of motion, while performing a musculoskeletal examination of a patient? Select all that apply. 1 Hip 2 Knee 3 Head 4 Finger 5 Elbow

4 Auscultation refers to listening to internal body sounds by way of a stethoscope. Palpation involves using touch to assess a patient's body. Inspection involves the use of visual, hearing, or olfactory abilities to assess a patient's body. Percussion involves the use of the fingertips to tap the skin and assess underlying tissues and organs of a patient's body.

Which physical assessment technique involves the use of a stethoscope? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

1, 3, 5 Palpation, percussion, and auscultation are all techniques the nurse uses during a physical examination. Palpation refers to assessing by touch. Percussion involves assessment by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to body sounds to detect variations from normal functioning. Evaluation and visualization are not formal techniques of physical examination.

Which physical examination techniques are most helpful when assessing a patient? Select all that apply. 1 Palpation 2 Evaluation 3 Percussion 4 Visualization 5 Auscultation

3 Knee-chest position is used to examine the rectum. Prone position is used to examine the musculoskeletal system. Supine position is used to examine the head and neck. Lateral recumbent position is used to examine the heart.

Which position is used for examining the rectum? 1 Prone 2 Supine 3 Knee-chest 4 Lateral recumbent

4 In the above figure, the dorsal pedis pulse is palpitated. It is measured by placing the fingertips between the first and second toes. The tibial pulse is measured by placing the fingers behind and below the medial malleolus. The femoral pulse is measured by placing the fingertips of both hands on opposite sides of the pulse site. The politeal pulse is measured by placing the fingertips of both hands deeply into the popliteal area.

Which pulse is palpated in the given figure? 1 Tibial pulse 2 Femoral pulse 3 Popliteal pulse 4 Dorsalis pedis pulse

3 A platform or basket scale is used to weigh infants. Bed and chair scales are used for patients who are unable to bear their own weight. A standing scale is used for patients who are capable of bearing their own weight.

Which scale is used to weigh infants? 1 Bed scale 2 Chair scale 3 Platform scale 4 Standing scale

4 According to the Glasgow Coma Scale, if the patient's best motor response is abnormal extension, the patient is given a score of 2. A score of 5 indicates that the patient's best motor response is localized pain. A score of 4 indicates that the patient's best motor response is flexion withdrawal. A score of 3 indicates that the patient's best motor response is abnormal flexion.

Which score is awarded to patient whose best motor response is abnormal extension, according to the Glasgow Coma Scale? 1. 5 2. 4 3. 3 4. 2

4 Pitting edema can be assessed by pressing the index finger firmly over the medial malleolus or the shins for several seconds. Phlebitis is the inflammation of a vein that occurs commonly after trauma to the vessel wall. The peripheral veins should be assessed in the sitting and standing position. The assessment of the peripheral veins includes inspection and palpation for varicosities, peripheral edema, and phlebitis.

Which statement regarding the assessment of the peripheral veins is true? 1 Phlebitis is the formation of edema in the legs. 2 The peripheral veins should be assessed in the prone position. 3 The assessment of peripheral veins includes inspection of peripheral edema and phlebitis. 4 Pitting edema can be assessed by pressing firmly for several seconds over the medial malleolus or the shins using the index finger.

3, 4 Palpation is a physical examination technique that involves using the sense of touch to gather information. It involves the use of different parts of the hand to detect various characteristics of body parts. Auscultation is a physical examination technique that involves listening to sounds the body makes. Percussion is a skill used more often by advanced practice nurses than by nurses in daily practice. Inspection involves the use of olfaction to detect abnormalities that cannot be recognized by any other means.

Which statements about palpation are correct? Select all that apply. 1 It is a physical examination technique that involves listening to sounds the body makes. 2 It is a skill used more often by advanced practice nurses than by nurses in daily practice. 3 It involves the use of different parts of the hand to detect various characteristics of body parts. 4 It is a physical examination technique that involves using the sense of touch to gather information. 5 It involves the use of olfaction to detect abnormalities that cannot be recognized by any other means.

1, 2 The glossopharyngeal nerve has both sensory and motor functions; it controls the ability to swallow and the sensation of taste. The vagus nerve controls the movement of the vocal cords. The trochlear nerve controls downward, inward eye movements. The abducens nerve controls the lateral movement of the eyeballs.

Which statements are true about the functions of the glossopharyngeal nerve? Select all that apply. 1 It controls the ability to swallow. 2 It controls the sensation of taste. 3 It controls the movement of the vocal cords. 4 It controls downward, inward eye movements. 5 It controls the lateral movement of the eyeballs.

1 The carotid arteries should not be palpated or massaged vigorously, because the carotid sinus is located at the bifurcation of the common carotid arteries in the upper third of the neck. This sinus sends impulses along the vagus nerve. The stimulation of the vagus nerve causes a reflex drop in heart rate and blood pressure, which causes syncope or circulatory arrest. This is a particular problem for older adults. While examining the carotid arteries, the patient must sit or lie in the supine position with the head of the bed elevated to 31 degrees. Asking the patient to sit during the procedure will not cause syncope.

While assessing the carotid artery, an older adult experiences syncope. Which action made by the nurse might have led to this condition? 1 Palpating the carotid arteries vigorously 2 Elevating the head of the bed to 31 degrees 3 Shifting the patient from sitting to a supine position 4 Asking the patient be in sitting position during the procedure

2, 3 The trigeminal nerve has both sensory and motor functions. It acts as the sensory nerve to the skin of the face. To assess this function, the nurse lightly touches the patient's cornea with a wisp of cotton to assess the corneal reflex and measures the sensation of light pain and touch across the skin of the face. The trigeminal nerve also acts as the motor nerve to the muscles of the jaw. To assess this function, the nurse palpates the patient's temples as the patient clenches the teeth. The facial nerve is responsible for controlling facial expressions. To assess this nerve, the nurse looks for asymmetry while the patient makes various facial expressions. The spinal accessory nerve is responsible for the movement of the head and shoulders. The vagus nerve provides parasympathetic innervation to glands of the mucous membranes of the pharynx, larynx, and organs in the neck, thorax, and abdomen. To assess this function, the nurse assesses the patient's heart rate and the presence of peristalsis.

While assessing the functions of a cranial nerve, the nurse lightly touches the patient's cornea with a wisp of cotton to assess the corneal reflex. The nurse also palpates the patient's temples as the patient clenches the teeth. What are the functions of the cranial nerve that are being assessed? Select all that apply. 1 Controlling facial expressions 2 Acting as the sensory nerve to the skin of the face 3 Acting as the motor nerve to the muscles of the jaw 4 Being responsible for the movement of the head and shoulders 5 Providing parasympathetic innervation to glands of the mucous membranes of the pharynx

1 The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Scale rating is used from 0 to 4 for the strength of a pulse. A score of 1 is given for pulse diminished and barely palpable. When the pulse is absent and not palpable, a score of 0 is given. A score of 2 indicates expected pulse. A score of 3 indicates full and increased pulse.

While assessing the strength of pulse in a patient, the nurse finds the pulse to be diminished and barely palpable. Which rating should the nurse include in the medical report? 1. 0 2. 1 3. 2 4. 3

4 The palmar surface of the fingers should be used to check the tenderness of skin. The palmar surface of the hand should be used to check the texture, moisture, and thickness of skin.

While palpating a patient's skin, a nurse uses the palmar surface of his or her fingers. Which criterion is being measured? 1 Texture 2 Moisture 3 Thickness 4 Tenderness

3 The nurse should pace the examination, pausing at intervals to ask how the patient is feeling. If the patient is not feeling well, the examination may be postponed because the findings may not be accurate. The examination may be continued if the patient feels all right. Remaining calm while examining the patient may help the patient relax; however, if the patient is weak, performing the examination calmly may not be helpful. The nurse may allow a family member in the examination room if the patient is of the opposite gender.

While preparing a patient for a physical examination, a nurse learns that the patient is elderly and very weak. Which nursing intervention is the most appropriate in this situation? 1 Postponing the examination 2 Performing the examination calmly 3 Pacing the examination, pausing at intervals 4 Allowing a family member in the examination room

4 If the patient is too weak to sit upright, the nurse should allow the patient to assume supine position with the head of the bed elevated, because this is the most relaxed position. Prone position is suitable for assessing extension of the hip joint, skin, and buttocks. Lateral recumbent position is suitable for assessing the heart. If a patient has painful disorders, the nurse should allow the patient to assume dorsal recumbent position with the knees flexed.

While preparing a patient for the physical examination of the thorax and lungs, a nurse finds that the patient is too weak to sit upright. Which nursing intervention is the most appropriate in this situation? 1 Allowing the patient to assume prone position 2 Allowing the patient to assume lateral recumbent position 3 Allowing the patient to assume dorsal recumbent position with the knees flexed 4 Allowing the patient to assume supine position with the head of the bed elevated

2, 5 To promote relaxation in an anxious patient while palpating, the nurse should ask the patient to take slow, deep breaths and place both the arms along the sides of the body. The nurse should warm the diaphragm of the stethoscope while auscultating, not palpating, a patient. The nurse should warm, not cool, the hands before touching the patient. While inspecting a patient's body, the nurse should make sure that adequate lighting is available. Ensuring adequate lighting during palpation may not help promote relaxation in the patient.

While preparing to palpate a patient's skin, the nurse notices that the patient is anxious. Which actions made by the nurse will help promote relaxation in the patient? Select all that apply. 1 Warming the diaphragm of the stethoscope 2 Asking the patient to take slow, deep breaths 3 Cooling the hands before touching the patient 4 Making sure that adequate lighting is available 5 Asking the patient to place both arms along the sides of the body