Health Assessment exam 3

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia?

Global

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding

Is expected.

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true

It helps equalize air pressure on both sides of the tympanic membrane

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation?

"Are you feeling so hopeless that you feel like hurting yourself now?"

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions?

"Are you having any disturbing dreams?"

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information?

"Do you have any warning sign before your seizure starts?"

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make?

"Does the tremor change when you drink alcohol?"

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?

"Does your baby seem to startle with loud noises?"

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?

Mild, even resistance to movement

When the nurse is testing the triceps reflex, what is the expected response?

Extension of the forearm

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:

Inappropriate affect

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?

Loss of lens elasticity

The nurse knows that testing kinesthesia is a test of a person's:

Position sense.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?

Optic disc that is a yellow-orange color

During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question?

"How do you feel today?"

A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to like to do." He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question?

"How long have you been feeling this way?"

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?

"I know my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2010."

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?

"I never did too good in school."

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

"Is there any relationship between the ear pain and the discharge you mentioned?"

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?

"Pick up the pencil in your left hand, move it to your right hand, and place it on the table."

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?

"Please point to articles in the room and parts of the body as I name them."

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas?

"Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom."

During a mental status assessment, which question by the nurse would best assess a person's judgment?

"Tell me what you plan to do once you are discharged from the hospital."

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

"Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be:

"You need to get up slowly when you've been lying down or sitting."

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

6

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?

Air conduction is the normal pathway for hearing.

The nurse is assessing the mental status of a child. Which statement about children and mental status is true?

All aspects of mental status in children are interdependent.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

Absence of drainage from the puncta when pressing against the inner orbital rim

man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?

Acute alcohol intoxication

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):

Acute otitis media.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is:

Otosclerosis.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?

Any prolonged exposure to extreme cold

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

Ask the patient if he or she has a history of heart failure.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to:

Ask the patient to lock her fingers and pull.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to

Ask the patient what medications he is currently taking.

A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests:

Chorea.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?

Assessing for other signs of ectropion

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

Astereognosis

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the

Auricle.

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate?

Before testing, the nurse would assess the patient's mental status and ability to follow directions

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

Bloody or clear watery drainage can indicate a basal skull fracture.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?

Cerebellum

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?

Cerebrum

A patient repeatedly seems to have difficulty coming up with a word. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs." The nurse will note on his chart that he is using or experiencing:

Circumlocution

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of:

Clanging

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding?

Cognitive impairment

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?

Complete neurologic examination

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of:

Compulsive disorder

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to:

Conduct vibrations of sounds to the inner ear.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would:

Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

Consider this a normal finding.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should

Consider this a normal finding.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

Constriction of both pupils occurs in response to bright light.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

Convergence of the axes of the eyes

The ability that humans have to perform very skilled movements such as writing is controlled by the:

Corticospinal tract.

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

Could be a potential carcinoma, and the patient should be referred for a biopsy

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

Dark retinal background

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n):

Decreased level of consciousness.

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?

Denver II

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply.

Develops over a short period; Person is exhibiting memory impairment or deficits; Occurs as a result of a medical condition, such as systemic infection

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply.

Difficulty performing familiar tasks, such as placing a telephone call; Misplacing items, such as putting dish soap in the refrigerator; Rapid mood swings, from calm to tears, for no apparent reason; Getting lost in one's own neighborhood

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?

Dysfunction of the cerebellum

During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of:

Echolalia

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

Elevates the eyelid and dilates the pupil.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

Enlarged superficial cervical nodes

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?

Gathering mental status information during the health history interview is usually sufficient.

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:

Give him the Four Unrelated Words Test.

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:

Has a snake phobia.

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient

Has poor vision.

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girl's mental status?

Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?

High-tone frequency loss

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to:

Hop on one foot.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

Hordeolum (stye).

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?

Hyperactive reflexes

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

Hyperreflexia

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:

Hyphema

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Hypomobility

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?

Hyporeflexia

During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest?

Increased intracranial pressure

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates

Increased intracranial pressure.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

Is a characteristic of recruitment.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding

Is a normal finding, and no further follow-up is necessary.

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant's parents that the Denver II:

Is a screening instrument designed to detect children who are slow in development.

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response:

Is a very ominous sign and may indicate brainstem injury.

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:

Know that floaters are usually insignificant and are caused by condensed vitreous fibers.

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should:

Know that these are scars caused from frequent ear infections

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is the:

Labyrinth

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient's level of consciousness would be:

Lethargic

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's:

Level of consciousness and cognitive abilities

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

Level of consciousness, motor function, pupillary response, and vital signs

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have

Macular degeneration.

During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?

Man believes that his dead wife is talking to him.

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:

May indicate disease of the cerebellum or brainstem.

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

May take a little longer to respond, but his general knowledge and abilities should not have declined.

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

Mental status functioning is inferred through the assessment of an individual's behaviors.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:

Most likely has serous otitis media

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

Motor component of CN VII

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

Moves the head and shoulders against resistance with equal strength.

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is:

Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

Nerve degeneration in the inner ear

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:

Normal changes attributable to aging.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

Notify the patient's health care provider

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

Objective vertigo

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?

Observe the distance between the palpebral fissures.

During an examination, the nurse can assess mental status by which activity?

Observing the patient and inferring health or dysfunction

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

Parallel movement of both eyes

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:

Parkinsonism.

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

Passive cigarette smoke

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma?Select all that apply

Patient experiences tunnel vision in the late stages; Vision loss begins with peripheral vision; Virtually no symptoms are exhibited

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

Pearly gray and slightly concave

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:

Perform the otoscopic examination at the end of the assessment.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

Peripheral neuropathy

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to:

Plan to defer the rest of the mental status examination.

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?

Plantar reflex present

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:

Positive Babinski sign, which is abnormal for adults.

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

Positive Romberg sign.

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:

Presence of dysdiadochokinesia.

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:

Presence of shadows, which may indicate glaucoma.

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?

Presence of small brown macules on the sclera

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply

Progression of hearing loss is slow; The aging person may find it harder to hear consonants than vowels; Sounds may be garbled and difficult to localize

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure?

Pulling the pinna down

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Pulling the pinna up and back before inserting the speculum

The nurse is testing a patient's visual accommodation, which refers to which action?

Pupillary constriction when looking at a near object

In a patient who has anisocoria, the nurse would expect to observe

Pupils of unequal size.

To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant:

Raises the head, and arches the back.

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.

Recall; after a 30-minute delay

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings?

Refer the infant for further testing.

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing?

Reflexes

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?

Reflexes will be normal.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?

Rubella can damage the infant's organ of Corti, which will impair hearing.

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:

Sensory-perceptive abilities

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

Shadow or diminished vision in one quadrant or one half of the visual field.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?

Shattered look to the light rays reflecting off the cornea

When assessing the pupillary light reflex, the nurse should use which technique

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

Shorten the distance between the patient and the chart until the letters are seen, and record that distance

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?

Spastic hemiparesis

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

Stimulated by CNs III, IV, and VI

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

Test for color vision once between the ages of 4 and 8 years.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and should

Test for strabismus by performing the corneal light reflex test.

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation?

The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

The normal membrane may appear thick and opaque

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

The outer layer of the eye is very sensitive to touch.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

The patient can read at 20 feet what a person with normal vision can read at 30 feet.

Which of these statements about the peripheral nervous system is correct?

The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

The purpose of cerumen is to protect and lubricate the ear.

The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?

The purpose of the tubes is to decrease the pressure and allow for drainage.

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements?

The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?

These findings are normal, resulting from aging.

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination?

This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?

This reflex should have disappeared between 1 and 4 months of age.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?

This response is most likely the result of the summation effect.

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates

Tinnitus.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:

Turns his or her head to localize the sound.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

Unequal pupillary constriction in response to light

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:

Use rubbing alcohol or 2% acetic acid eardrops after every swim.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

Use the Snellen chart positioned 20 feet away from the patient.

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?

VIII

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as:

Vertigo.

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best description of this patient's problem?

Wernicke's aphasia

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Whisper a set of random numbers and letters, and then ask the patient to repeat them.

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:

Will be oriented to place and person, but the patient may not be certain of the date.

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest?

Yeast or fungal infection