HA Ch 16,17,18,19

31.-The client asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?

"It identifies a problem with the normal pathways for sound to travel to your inner ear."

28. A 6 year old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye?

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." (p. 321)

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

"You have a conductive hearing loss."

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

Stridor

61.-Which glands are responsible for mouth drainage? Select all that apply.

Sublingual.Submandibular.Parotid

27.-In palpating the chest of a client a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?

Suprasternal notch

9.-The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?

Teaching strategies to reduce complications of existing diagnoses

55. 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?

The area around the sac is inflamed (p. 323)

5. 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. (p. 318).

38.-A nurse is admitting a client to the hospital. When reviewing the client's medical record the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?

The client has unilateral hearing loss

41. A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity.(p. 316)

20.-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.

13.-Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction.

29.-A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus

48.-A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus

14.-The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss?

The sound is better in the ear in which he has better hearing.

45.-A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear

40. A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light (p. 324)

46. What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client?

Thick, purulent drainage is noted at inner corner of both eyes.

29.-A 58-year-old man who is HIV-positive has presented with thick white plaques on his oral mucosa. What diagnosis would the nurse first suspect?

Thrush

21.-During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates loop diuretics, quinidine, quinine, or aminoglycosides?,

Tinnitus and sensorineural hearing loss

48.-When assessing a client the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils?

Tonsils are T3

37.-When assessing the client's risk for hearing loss it is important to ask about the history of exposure to noise. What related client teaching would be important? (Select all that apply.)

Types of protective equipment usedInstructions for the use of protective ear equipmentEffectiveness of protective equipment

3. When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in what direction

Up (p. 321-322)

12. How can a nurse accurately assess the distant visual activity of a client who is non English speaking?

Use a Snellen E chart to perform the examination (p. 316)

60.-Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia?

Vegetable omelet

12.-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?,

Vertigo

13.-When visualizing the structures of the nose the nurse recalls that air travels from the anterior nares to the trachea through the

Vestibule, nasal passages, and nasopharynx

23.-During the nursing assessment the nurse identifies the client has a smooth glossy tongue. The nurse understands this is caused by what?

Vitamin B12 deficiency

27.-The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client?

Vitamin deficiency

43.-The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is composed of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air

49.-You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?

Warm the inspired air

33-Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?,

,Red, bulging, with an absent light reflex

51.-A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+ how should the nurse appropriately document the tonsils?

1+

14.-When assessing the posterior chest what is a starting point for counting ribs and interspaces?

12th rib

41.-Upon assessment of the tonsils the nurse finds them to be obstructing 30% of midline. This nurse would document this as what?

2+

10. Which Vision acuity reading indicates blindness?

20/200 (p. 307)

48. A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less (p. 317)

37.-The nurse examines the pharynx of a client and records that the tonsils are touching the uvula. The nurse would grade the tonsils as

3+

57.-A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching the uvula. Using a grading scale of 1+ to 4+ how should the nurse appropriately document the tonsils?

3+

3.-A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+ how should the nurse appropriately document the tonsils?

4+

3.-An increased risk of falls is dangerous for any client. What client would be at an increased risk of falls?

A client with vertigo.

46.-A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?

A grey-white line

21.-A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?

A large amount of exudate in the sinuses

14. You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

A left temporal hemianopsia (p. 330).

54.-A client has Darwin tubercle. What is this?

A small painless nodule on the helix

35. The functional reflex that allows the eyes to focus on near objects is termed

Accommodation (p. 307)

31.-A client presents to the health care clinic with reports of a 3-day history of fever sore throat and trouble swallowing. The nurse notes that the client is febrile with a temperature of 101.5°F tonsils are 2+ and red and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?

Acute Pain

10.-Which description of exterior landmarks indicates normal positioning of the lungs?

Anteriorly the lower border of the lung crosses the 6th rib at the midclavicular line.

24.-While inspecting the thorax the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter

53.-When collecting a client's medical history the nurse should ask if the client is taking which medications that most likely contribute to complaints of recurrent epistaxis? (Select all that apply.)

Anticoagulants . Herbal supplements. Antihistamines

7. The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes the condition, common in older adults, as which of the following?

Arcus senilis (p. 323)

44. A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

Ask the client about previous trauma to the eyes (p. 323)

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

Ask the client to say "aaah"

7.-A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?

Ask the mother how long the tubes have been in place.

59.-Upon inspection of an elderly client's ears using an otoscope the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first?

Ask whether the client is experiencing ear pain or pressure

42.-High doses of this medication can produce bilateral tinnitus?

Aspirin

18. 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 ft (p. 317)

43.-As a part of the ear examination for hearing loss a nurse conducts a Weber test on a client. To accurately perform this test the nurse should place the base of the tuning fork in which of the following locations?

At the center of the client's forehead

52.-As a part of the ear examination for hearing loss a nurse conducts a Weber test on a client. To accurately perform this test the nurse should place the base of the tuning fork in which of the following locations?

At the center of the client's forehead

23-When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.),

At train stations, Using lawnmowers, At concerts

15.-A nurse is assessing the mouth of a client and finds that she has a smooth red shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12

4.-A nurse is assessing the mouth of a client and finds that she has a smooth red shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12

55.-A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding the nurse should suspect which of the following causes?

Bacterial infection

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

Blunt force trauma often results in fracture of the orbit (P. 304)

25. Blunt force trauma often results in fracture of the orbit

Blunt force trauma often results in fracture of the orbit (p. 317)

34. A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?

Brain tumor (p. 308).

42. The conjunctiva of the eye is divided into the palpebral portion and the

Bulbar portion (p. 304)

40.-The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely

Candida albicans infection.

59.-A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client?

Chewing betel nuts

22.-What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?

Cheyne-Stokes

53. The middle layer of the eye is known as the

Choroid layer (p. 305)

29.-A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?

Chronic obstructive lung disease

54. The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

Cleanse the cornea and the lens (p. 306)

40.-During the lung assessment for a client with pneumonia the nurse auscultates low-pitched bubbling moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles

1. The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva (p. 304)

45. A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?

Conjunctiva (p. 322).

33. The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding?

Consensual light response present in left eye (p.324)

22.-A nurse is inspecting the ears of an Asian client and observes that her earlobes appear solderedor tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?,

Continue with the examination

44.-A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered or tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?

Continue with the examination

30. An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to

Corneal damage (p. 309)

39.-A nurse performs an initial examination of a client brought to the emergency department after sustaining a head injury in an automobile accident. Which characteristic of discharge from the ears should alert the nurse that the client has a cerebrospinal fluid leak?

Watery or bloody

40.-The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber's test

62.-The submandibular glands open under the tongue through openings called

Wharton ducts.

29. A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses (p. 309)

22.-A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?

Cranial nerve XII (hypoglossal)

14.-A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?

Cyanotic

51. A nurse examines a client's retina during the ophthalmic examination and notices light colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Diabetes (p. 326)

19. The nurse is teaching about the importance of regular eye examination and should include information about which conditions that place clients at highest risk for blindness?

Diabetes.Hypertension (p. 326)

12.-Which of the following muscles is primarily responsible for thoracic cavity enlargement?

Diaphragm

2.-Which question asked by the nurse is assessing problems with tinnitus?

Do you experience buzzing in your ears?"

15. The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should?

Document the findings in the client's records. (p. 330)

34.-What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

Dullness

57.-What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

Dullness

34.-A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

Dysphagia

2.-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

39.-During assessment of the oral cavity the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

Either side of the frenulum on the floor of the mouth

23. Which action by the nurse indicates the appropriate use of an ophthalmoscope?

Employ the right eye to examine the client's right eye (P. 317)

7.-The client has been admitted through the emergency department with chronic bronchitis has elevated CO2 levels and has been placed on O2. What priority assessment would the nurse include?

Evaluate changes in respiratory pattern and rate.

26. Blunt force trauma often results in fracture of the orbit

Exopthalmos (p. 321)

8. What is a characteristic symptom of Graves hyperthyroidism

Exopthalmos (p. 321)

17. When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding?

Exotropia (p. 319)

58.-An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination she has pain when the ear including the tragus is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client?

External otitis

45.-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

39. A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?

Focused on the bridge of the nose (p. 319)

51.-A nurse asks a client to say "ninety-nine" while palpating the posterior thorax. The nurse is demonstrating effective technique in assessing for what respiratory characteristic?

Fremitus

21.-What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

Friction rub

33.-The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

Funnel chest

63.-During an assessment the nurse observes the condition shown in the client's mouth. What should the nurse suspect is occurring with this client?

Gingival hyperplasia

19.-In order to effectively assess the oral mucosa the nurse should have which assessment tools available?

Gloves. Penlight. tongue depressor

15.-A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray

9. What information, acquired during an eye assessment and history, would the nurse document as lifestyle habits?

Has smoked for last 12 years.Uses sunglasses when outdoors.Uses protective eyewear when appropriate

2. A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?

Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time (p. 318)

22. The nurse is planning to assess a client's near vision. Which technique should be used?

Have the client read newspaper print held 14 inches from the eyes (p. 316)

56.-A client is concerned about developing lung cancer as he smoked for years. He tells the nurse that he quit smoking last year but wonders if there is anything else he can do to reduce his risk for developing this disease. Which of the following should the nurse recommend?

Having his home checked for radon

11.-The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test

27.-The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test

55.-The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test

30.-The thoracic cavity contains which of the following organs? Select all that apply.

Heart. Lungs. Most of the esophagus

47.-The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear

2.-You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?

Hoarseness

28.-A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client complains of ear pain. The nurse practitioner is performing an otoscopic examination. What would demonstrate the correct technique for using the otoscope?

Holding the otoscope so that the thumb is by the window, Holding the client's ear at the helix, Rotating the otoscope slightly

17.-A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose mouth throat and sinuses. What would the educator include in the presentation?

How to reduce periodontal disease

46.-A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

Hyperresonance

47. A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

Hyphema

36.-During an assessment the nurse observes the client's throat as shown. Which cranial nerve should the nurse suspect is damaged in this client?

X

38. A client comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?

You will need to see the doctor to have your eyes checked

54.-A client presents to the health care facility with a 2-week history of persistent dry hacky cough chest tightness and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

Impaired Gas Exchange

11. Which features would most likely be noted on funduscopic examination of someone with glaucoma?

Increased cup-to-disc ratio (p. 334)

53.-A client presents to the health care facility with sudden onset of shortness of breath inability to lie flat and a deep wet cough. A nurse observes a respiratory rate of 18 breaths per minute use of accessory muscles to breathe and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?

Ineffective Airway Clearance

26.-A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully

4. A middle aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

Instruct the client to hold the chart 14 inches from the eyes

20.-The nurse auscultates the base of the lungs to assess for what reason?

It is where fluid occurs with pulmonary edema.

11.-An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?

Kiesselbach plexus

21. A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus (p. 308)

32. A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus (p. 308)

36. An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for

Lacrimal obstruction (p. 308)

50.-A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

Laryngeal cancer

55.-A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

Laryngeal cancer

54.-An older client who wears dentures complains of having sore gums. What can the nurse instruct the client to help with this problem?

Massage the gums every day.

52. What are the glands that are located on the tarsal plates and open on the lid margins?

Meibomian glands (p. 304)

13.-Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage

5.-When teaching a class of school-age children about hygienehe nurse should include which information about the ears?,

Never put anything smaller than your elbow in your ears.

34.-The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed and the client denies pain or tenderness. What is the nurse's best action?,

Notify the healthcare provider about the finding.

23.-A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

Observe for the use of accessory muscles

6.-When auscultating the lungs the nurse listens over symmetrical lung fields for which of the following?

One deep inspiration and expiration through the open mouth

10-A client calls the clinic and tells the nurse that the doctor told her that she has "otalgia." The client cannot remember what the doctor explained this to be. How would the nurse most appropriately respond?

Otalgia is pain in the ear."

18.-A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

51.-Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?

Otosclerosis

32.-You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?

Pain on manipulation of the auricle

50.-You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?

Pain on manipulation of the auricle

56.-A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?

Pallor

52.-The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?

Palmar base

47.-On assessing a client's mouth the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client?

Paralysis of cranial nerve X (vagus)

18.-A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority?

Patient C

50. Equipment used for objective data collection involving the eyes includes which of the following? Select all that apply.

Penlight.Ophthalmoscope.Snellen chart.Occlusive covers (p. 315)

60.-A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss?

Perforated eardrum

13. On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

Perform both the distant and near visual acuity tests (p. 318)

1.-Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test?

Place arms around the client without touching

3.-Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9 press thumbs together and then ask client to take a deep breath

39.-The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?

Pleural effusion

31.-A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

Pleurisy

15.-A bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal

angle.

16.-The apex of each lung is located at the

area slightly above the clavicle.

36.-The apex of each lung is located at the

area slightly above the clavicle.

44.-The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

ask the client to breathe deeply through her mouth.

28.-While assessing an adult client the nurse observes decreased chest expansion at the bases of the client's lungs. The nurse should refer the client to a physician for possible

chronic obstructive pulmonary disease.

53.-The nurse has performed the Rinne test on an older adult client. After the test the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing

conductive hearing loss.

26.-The transmission of sound waves through the external ear and the middle ear is known as?

conductive hearing.

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

cyanotic

25.-The nurse is planning to inspect an adult client's mouth using a tongue depressor. The nurse should plan to

depress the tongue blade slightly off center.

43.-The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis.

8.- Before examining the mouth of an adult client the nurse should first

don clean gloves for the procedure.

24.-In the hearing pathwayhair cells of the spiral organ of Corti are stimulated by movement of ?,

fluid.

49. When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark skinned individuals?

fundus is grayish brown with a purplish cast (p. 321)

18.-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?

herpes simplex

50.-After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?

hyperresonance

35.-The clavicles extend from the acromion of the scapula to the part of the sternum termed the

manubrium.

24.-The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses the nurse should proceed to examine the

maxillary sinuses.

7.-The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses the nurse should proceed to examine the

maxillary sinuses.

35.-The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client the nurse should

observe the client's response to the explanations.

42.-The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's

pectus excavatum.

37.-While assessing an adult client's lungs during the postoperative period the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

pneumonia.

31. 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. (p. 316)

9.-The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to

position the handle of the otoscope to one side.

17.-While assessing the thoracic area of an adult client the nurse plans to auscultate for voice sounds. To assess bronchophony the nurse should ask the client to

repeat the phrase "ninety-nine."

25.-The nurse is planning to conduct the Weber test on an adult male client. To perform this test the nurse should plan to?,

strike a tuning fork and place it on the center of the client's head or forehead.

61.-An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been

taking antibiotics.

8.-An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been?

taking antibiotics.

26.-An adult client visits the clinic complaining of a sore throat. After assessing the throat the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are

touching each other.

38.-The nurse auscultates very loud high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds?

trachea

8.-An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

tuberculosis.

19.-Which terms are used to identify the lobes of the right lung? Select all that apply.

upper lobe.middle lobe .lower lobe

49.-A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear

whispered sounds

5.-A 47-year-old receptionist comes to the office with fever shortness of breath and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain weight loss or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco alcohol or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head eyes ears nose and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion increased fremitus during palpation and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

Pneumonia

16.-Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

30.-The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult?

Presbycusis

6. A nurse notices a middle aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?

Presbyopia (p 318)

1.-A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.)

Press up on the frontal sinuses from under the bony brows. Press up on the maxillary sinuses.

20.-A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.)

Press up on the frontal sinuses from under the bony brows.Press up on the maxillary sinuses.

49.-The client tells the nurse that he has been coughing up pink frothy sputum. The nurse notifies the health care provider because the client may have what condition?

Pulmonary edema

16. When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze, dilation on distant gaze (p. 324).

16.-Which instructions should the nurse provide to the client taking a sublingual medication?

Put the medication underneath your tongue.

32.-A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

Receding and ischemic gums

5.-A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

Receding and ischemic gums

28.-Which assessment of the tongue should a nurse recognize as abnormal?

Red with loss of papillae

17-Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex

12.-A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?

Red, swollen, with purulent discharge

38.-Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?

Red.bleeding

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

Resonance

25.-When percussing the posterior lung fields which of the following findings is expected?

Resonance over all lung fields

20. Photoreceptors of the eye are located in the eye's

Retina (p. 305)

57.-A nurse performs a Rinne test on a client who relates a history of decreased hearing in the right ear. The test demonstrates that the client has conductive hearing loss in the right ear. What is the correct documentation of this test by the nurse?

Right: BC greater than AC; left AC greater than BC

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

Rinne

33.-A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?

Rinse mouth with antifungal medication as prescribed.

6.-A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?

Rinse mouth with antifungal medication as prescribed.

41.-The spinous process termed the vertebra prominens is in which cervical vertebra?

Seventh.

27. Blunt force trauma often results in fracture of the orbit

She can see at 20 feet what a normal person could see at 100 feet. (p. 317)

47.-A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration

10.-The nurse is performing the assessment shown. What is the nurse assessing in this client?

Sinuses

30.-A nurse should assist a client to assume what position to best assess the mouth nose and sinuses?

Sitting with the head erect and at the eye level of the nurse

46.-The nurse is presenting an educational event for gardeners. When discussing the ears what would be an important topic to cover?

Skin cancer prevention

45.-On examination of a client the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process?

Small bowel obstruction

37. The nurse is caring for a 63yearold client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision?

Snellen E (p. 316)

48.-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.

52.-A nurse inspects the gums and teeth of a middle-aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?

"Are you experiencing any tooth pain?"

58.-A nurse inspects the gums and teeth of a middle-aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?

"Are you experiencing any tooth pain?"

42.-A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client?

"Are you experiencing sinus pressure and congestion?'

43. Which question should the nurse ask when assessing a client for a possible detached retina?

"Are you seeing flashing lights?" (p. 326)

11.-A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath change in activity level or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

4.-A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?"

19.-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?

"Have you had any recent trauma to the inside of your ear?"

56.-A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?

"Have you taken any antibiotics in the past few weeks?"