Health Assessments Nursing Ch. 15, 16, 17, 21, 25

The area of auscultation located at the second intercostal space at the right sternal border is called the :

Aortic area

The atrioventricular valves of the heart are located:

At the entrance to the ventricles

One sided facial paralysis is the characteristic of which of the following conditions?

Bell's Palsy

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?

Bruit

The patient says during the assessment that his headache typically occurs in the late evening or night. The nurse understands that the patient might be experiencing which o the following head ache?

Cluster Headache

The patient presents with a moon shaped face with reddened cheeks and increased facial hair. The nurse understands that patient has which of the following conditions?

Cushing's Syndrome

Exophthalmos is most commonly seen in which of the following conditions?

Hyperthyroidism

The nurse who is caring for the patient says to the nursing student that it is important to avoid bilateral compression of the carotid arteries. What is the rationale behind the nursing action?

It can reduce the blood supply to the brain.

If the nurse suspects the patient has meningeal irritation or inflammation, the nurse should perform the (Select all that apply)

Kernig's sign. Brudzinski's sign.

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

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

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

The nurse assessing a patient observes that the patient walks with a shuffling gait in a stiff manner and has stooped over posture with flexed hips and knees. The nurse recognizes this gait is typically found in patients with

Parkinson's disease.

Distention of the jugular vein may indicate:

Right side heart failure

To assess for unsteadiness or swaying, the nurse performs the

Romberg test.

The heart sound caused by the closure of the AV valves is

S1

The nurse is having difficulty differentiating between heart sounds. The nurse bases identification on the knowledge that

S1 is caused by the closure of the AV valves; S2by the closure of the aortic and pulmonic valves.

In a normal circumstance, the normal heartbeat is generated by the

SA node.

The patient in the medical floor suddenly experiences trouble seeing; trouble walking, dizziness or loss of balance. The nurse understands that patient may be experiencing which of the following?

Stroke

The nurse, while assessing heart sounds, hears a swishing sound. The nurse recognizes this sound is

a murmur caused by turbulant blood flow through the heart valves.

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

accommodation

Risk factors for hearing loss include

age greater than 65.

An adult patient tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should have the patient evaluated for

allergies.

To assess for motor function of cranial nerve 5, the nurse

asks the patient to clench the teeth while the nurse palpates the temporal and masseter muscles for contraction.

While assessing the carotid pulse, the nurse incorporates into the assessment the technique of (choose all that apply)

avoiding compressing the carotid sinus to avoid causing bradycardia. auscultating the carotid artery before palpating to avoid changing the heart rate. using the bell of the stethoscope with light pressure over the artery.

When assessing the patient's deep tendon reflexes, the nurse includes (Select all that apply)

biceps reflex. brachioradialis reflex. triceps reflex patellar reflex.

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

corneal damage.

During the neurological assessment, the nurse asks the patient to smile, frown, show their teeth, puff out the cheeks, purse the lips, raise the eyebrows, and close the eyes tightly against resistance. The nurse is assessing

cranial nerve 7.

The nurse has tested an adult patient's visual fields and determined that the temporal vision field is 90 degrees in both eyes.

document the findings as normal.

The Glascow Coma Scale is used to rate one's response to stimuli. The scale assesses for response to (Select all that apply)

eye opening response. verbal response. most integral motor response.

The nurse uses a blunt instrument to write a number or letter on the palm of the patient's hand while the patient closes his eye. The nurse then asks the patient to identify what was written. The nurse is testing for

graphesia

When for auscultating for heart sounds, the nurse takes the following action(s) (Select All That Apply)

instructs the patient not to hold his/her breath

A 26 y/o woman was involved in a motor vehicle accident and brought to the ER. While assessing the ears of patient, the nurse observes bloody drainage at the opening of the left ear. The nurse should

notify the physician.

A patient complains of pain when the nurse pulls the auricle up and back. This assessment finding indicates

otitis externa.

Miosis is a termed used to describe

pinpoint pupils.

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

sit in an upright position

The ossicles contained in the middle ear include the malleus, the incus, and the

stapes

The nurse is doing a neurological assessment on an adult patient. The nurse knows the lobe of the brain that receives and interprets impulses from the ear is the

temporal lobe.

The nurse is assessing a patient for conductive hearing. The nurse explains to the patient that conductive hearing is

transmission of sounds waves through the external and middle ear.

To test for the Planter reflex, the nurse

uses the end of the reflex hammer to stroke the lateral aspect of the sole from the heel to the ball of the foot.

The QRS complex of the EKG represents:

ventricular depolarization