nursing 2 pt 2

a. tell the client that these often occur with aging

a 45-yr old client tells the nurse that he occasionally sees spots in front of his eyes. the nurse should a. tell the client that these often occur with aging b. refers the client to an ophthalmologist c. re-examine the client in 2 weeks d. assess the client for signs of diabetes

a. angle

a bone ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal a. angle b. notch c. space d. prominens

d. refer the client to an optometrist

a client has tested 20/40 on the distant visual acuity test using a Snellen chart. the nurse should a. document the results in the client's record b. ask the client to read a handheld vision chart c. ask the client to return in 2 weeks for another examination d. refer the client to an optometrist

d. vitamin A deficiency

a client tells the nurse that she has difficulty seeing while driving at night. the nurse should explain to the client that night blinds is often associated with a. retinal deterioration b. head trauma c. migraine headaches d. vitamin A deficiency

d. riboflavin

a client visits the clinic and tells the nurse that she has painful cracking in the corners of her lips. the nurse should assess the client's diet for a deficiency of a. vitamin c b. fluoride c. vitamin a d. riboflavin

b. refer the client to an ophthalmologist

a client visits the local clinic after experiencing head trauma. the client tells the nurse that he has a consistent blind spot in his right eye. the nurse should a. examine the area of head trauma b. refer the client to an ophthalmologist c. assess the client for double vision d. ask the client if he sees "halos"

a. refer the client for further evaluation

a nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. the nurse should a. refer the client for further evaluation b. document the presence of herpes simplex c. ask the client if his gums bleed d. document the presence of a canker sore

d. stress and anxiety

an adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. the nurse should explain to the client that grinding the teeth may be a sign of a. precancerous lesions b. poor oral hygiene c. malabsorption d. stress and anxiety

c. check the client's BP

an adult client tells the nurse that he has been experiencing gradual vision loss. the nurse should a. ask about the client's diet b. determine whether there is a history of glaucoma c. check the client's BP d. ask the client if he has any known allergies

a. glaucoma

an adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. the nurse should refer the client for evaluation of possible a. glaucoma b. increased intracranial pressure c. bacterial infection d. migraine headaches

d. corneal damage

an adult client tells the nurse that his eyes are painful because he left his contact lenses into long the day before yesterday. the nurse should instruct the client that prolonged wearing of contact lenses can lead to a. retinal damage b. cataracts c. myopia d. corneal damage

a. high serum blood levels of low-density lipoproteins

an adult client tells the nurse that his father died of a massive coronary attach at the age of 65. the nurse should explain to the client that one of the risk factors for coronary heart disease is a. high serum blood levels of low-density lipoproteins b. low-carbohydrates diets c. high serum levels of high-density lipoproteins d. diets that are high in antioxidant vitamins

b. UV light exposure

an adult client tells the nurse that his father had cataracts. he asks the nurse about risk factors for cataracts. the nurse should instruct the client that a potential risk factor is a. lack of vitamin c in the diet b. UV light exposure c. obesity d. use of antibiotics

d. allergies

an adult client tells the nurse that she frequently experiences burning and itching of both eyes. the nurse should assess the client for a. foreign body b. recent trauma c. blind spots d. allergies

b. angina

an adult client visits the client and tells the nurse that she feels chest pain and pain down her left arm. the nurse should refer the client to physician for possible a. congestive heart failure b. angina c. palpitations d. acute anxiety reaction

d. TB

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 physical for possible a. pulmonary edema b. bronchitis c. asthma d. TB

b. increased intracranial pressure

an adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few ays. the nurse refers the client to a physician for evaluation of possible a. glaucoma b. increased intracranial pressure c. HTN d. ophthalmic migraine

d. lacrimal obstruction

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 a. viral infection b. double vision c. allergic reactions d. lacrimal obstruction

d. refer the client for further evaluation

an adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. the nurse should a. ask the client if she has had recent oral surgery b. assess the client's nasal passage for blockage c. ask the client if she is a smoker d. refer the client for further evaluation

d. head trauma

an adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. the nurse should explain to the client that sudden changes in vision are often associated with a. diabetes b. the aging process c. HTN d. head trauma

c. touching each other

an adult client visits the clinical complaining of a sore throat. after assessing the throat, the nurse documents the client's tonsils at 4+. the nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are a. touching the uvula b. visible upon inspection c. touching each other d. midway between the tonsillar pillars and uvula

d. a foreign body in the eye

an adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. the nurse should assess the client for a. recent exposure to irritants b. increased intracranial pressure c. excessive tearing d. a foreign body in the eye

a. uvula

an extension of the soft palate of the mouth, which hangs in the posterior midline of the oropharynx, is the a. uvula b. frenulum c. taste buds d. sublingual fold

d. don clean gloves for the procedure

before examining the mouth of n adult client, the nurse should first a. ask the client to leave dentures in place b. don sterile gloves for the procedure c. offer the client mouthwash d. don clean gloves for the procedure

c. apex of the heart

during a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's a. base of the heart b. pulmonic valve area c. apex of the heart d. second left interspace

c. retina

photoreceptors of the eye are located in the eye's a. ciliary body b. lens c. retina d. pupil

d. rectus muscles

straight movements of the eye are controlled by the a. lacrimal muscles b. oblique muscles c. corneal muscles d. rectus muscles

d. can be heard during diastole

the S4 heart sound a. can be heard during systole b. is often termed ventricular gallop c. is usually due to a heart murmur d. can be heard during diastole

d. precordium

the anterior chest area that overlies the heart and great vessels is called the a. endocardium b. epicardium c. myocardium d. precordium

b. area slightly above the clavicle

the apex of the lung is located at the a. level of the diaphragm b. area slightly above the clavicle c. level of the 6th rib d. left oblique fissure

a. between the left atrium and left ventricle

the bicuspid, or mitral, valve is located a. between the left atrium and left ventricle b. between the right atrium and right ventricle c. at the beginning of the ascending aorta d. at the exit of each ventricle near the great vessels

c. protector

the bony orbit and dat cushion of the eye serves as a a. caruncle b. channel c. protector d. filter

d. cleanse the cornea and the lens

the chambers of the eye contain aqueous human, which helps to maintain intraocular pressure and a. transmit light rays b. maintain the retinal vessels c. change refractory of the lens d. cleanse the cornea and the lens

b. manubrium

the clavicles extend from the acromion of the scapula to the part of the sternum termed the a. body v. xiphoid process c. angle d. manubrium

d. evaluate changes in respiratory pattern and rate

the client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 feels and has been placed on O2. what priority assessment would the nurse include a. assess for signs of nonproductive cough b. review blood work including RBC and WBC c. assess the characteristics of sputum d. evaluate changes in respiratory pattern and rate

d. bulbar portion

the conductive of the eye is divided into the palpebral portion and the a. canthus portion b. intraocular portion c. nasolacrimal portion d. bulbar portion

b. accommodation

the functional reflex that allows the eye to focus on near objects is termed a. pupillary reflex b. accommodation c. refraction d. indirect reflex

d. cilia

the lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the a. bronchioles b. alveolar sacs c. alveolar ducts d. cilia

a. an oily substance to lubricate the eyes

the meibomian glands secrete a. an oily substance to lubricate the eyes b. sweat c. hormones d. clear liquid tears

a. choroid layer

the middle layer of the eye is known as the a. choroid layer b. scleral layer c. retinal layer d. optic layer

a. chronic bronchitis

the nurse assess an adult client and observes that the client's breathing pattern is very labored and nosy, with occasional coughing. the nurse should refer the client to a physician for possible a. chronic bronchitis b. atelectasis c. renal failure d. congestive heart failure

b. pectus excavatum

the nurse assess the adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. the nurse should document the client's a. pectus thorac b. pectus excavactum c. pectus carinatum d. pectus diaphragm

d. increased central venous pressure

the nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. the nurse contacts the client's physician because the client's signs are indicative of a. pulmonary emphysema b. diastolic murmurs c. patent ductus arteriosus d. increased central venous pressure

d. bronchitis

the nurse assesses an adult client's breath sounds and hears sonorous wheezes, primarily during the client's expiration. the nurse should refer the client to a physician for possible a. asthma b. chronic emphysema c. pleuritis d. bronchitis

a. obstructive lung disease

the nurse detects paradoxical pulses in an adult client during examination. the nurse should explain to the client that paradisal pulses are usually indicative of a. obstructive lung disease b. left-sided heart failure c. premature ventricular contractions d. aortic stenosis

d. recognize that this finding is normal in adolescence

the nurse has assessed the heart sounds of an adolescent client and detects the presence of an S3 heart sound at the beginning of the diastolic pause. the nurse should instruct the client that she should a. be referred to a cardiologist for further evaluation b. be examined again in 6 months c. restrict exercise and strenuous activities d. recognize that this finding is normal in adolescence

d. an upper respiratory infection

the nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. the nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to a. too much smoking b. chronic allergies c. trauma to the nasal passages d. an upper respiratory infection

a. diabetes ketoacidosis

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 indicates a. diabetic ketoacidosis b. central nervous system injury c. drug overdose d. congestive heart failure

b. document the findings in the client's record

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 a. refer the client for further evaluation b. examine the client for other signs of glaucoma c. ask the client if there is a genetic history of blindness d. document the findings in the client's records

b. decreased accommodation

the nurse has tested the near visual acuity of a 45-yr old client. the nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. the nurse determines that the client has understood the instructions when the client says the presbyopia is usually due to a. congenital cataracts b. decreased accommodation c. muscle weakness d. constant misalignment of the eyes

b. area underneath the tongue

the nurse is asking an adult client's oral cavity for possible oral cancer. the nurse should explain to the client that the most common site of oral cancer is the a. area on top of the tongue b. area underneath the tongue c. inside of the cheeks d. area near the salivary glands

a. Candida albicans infections

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 a. Candida albicans infection b. koplik spots c. leukoplakia d. fordyce spots

a. aspiration

the nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. the nurse should instruct the client that she may be at greater risk for a. aspiration b. malocclusion c. gingivitis d. throat soreness

b. 3rd to 5th ICS at the left sternal border

the nurse is auscultating the heart sounds of an adult client. to auscultate Erb point, the nurse should place the stethoscope at the a. 2nd ICS at the right sternal border b. 3rd to 5th ICS at the left sternal border c. apex of the heart near the midclavicular line (MCL) d. 4th to 5th ICS at the left sternal border

b. 2 years

the nurse is caring for a healthy adult client with no history of vision problems. the nurse should tell the client that a thorough eye examination is recommended any a. year b. 2 years c. 3 years d. 4 years

c. requires the covering of each eye separately

the nurse is examining an adult client's eyes. the nurse has explained the positions test to the client. the nurse determines that the client needs further instructions when the client says that the positions test a. assesses the muscle strength of the eye b. assesses the functioning of the cranial nerves innervating the eye muscles c. requires the covering of each eye separately d. requires the client to focus on an object

d. lowering elevated cholesterol and BP decreases the risk of heart attack

the nurse is planning a presentation about coronary heart disease for a group of middle-aged adults. which of the following should be included in the nurse's teaching plan a. hispanic clients have a higher incidence of CHD than black of white Americans b. the incidence of HTN in the white population of the U.S is greater than in the black population c. woman are more likely to have serious stenosis after a heart attack d. lowering elevated cholesterol and BP decreases the risk of heart attack

a. diets low in fruits and vegetable are a positive risk factor for oral cancer

the nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. which of the following should be included in the nurse's plan? a. diets low in fruits and vegetable are a positive risk factor for oral cancer b. about 40% of all cancers occur in the lips, mouth, and tongue c. the incidence of oral cancers is higher in women then in men d. most oral cancers are detected in people in their 70s

d. studies have indicated that there is a genetic component in the development of lung cancer

the nurse is planning a presentation to a group of high school students of the topic of lung cancer, which of the following should the nurse plan to include in the presentation? a. compared with whites in the U.S, African Americans have a lower incidence of lung cancer b. lung cancer is the 3rd leading cause of death in the US c. there is a higher incidence of lung cancer in women than men in the U.S d. studies have indicated that there is a genetic component in the development of lung cancer

a. ask the client to hold her breath

the nurse is planning to auscultate a females adult client's carotid arteries. the nurse should plan to a. ask the client to hold her breath b. palpate the arteries before auscultation c. place the diaphragm of the stethoscope over the artery d. ask the client to breathe normally

a. depress the tongue blade slightly off center

the nurse is planning to inspect an adult client's mouth, using a tongue depressor. the nurse should plan to a. depress the tongue blade slightly off center b. depress the tongue blade as close to the center as possible c. ask the client to keep the mouth partially open d. insert the tongue blade at the back of the client's tongue

d. asking the client to exhale forcefully and hold his breathe

the nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. the nurse should begin by a. asking the client to take a deep breath and hold it b. percussing upward from the base of the lungs c. percussing downward until the tone changes to resonance d. asking the client to exhale forcefully and hold his breathe

a. position the client 609.6cm (20ft) away from the chart

the nurse is preparing the examine an adult client's eye, using a Snellen chart. the nurse should a. position the client 609.6cm (20ft) away from the chart b. ask the client to remove his glasses c. ask the client to read each line with both eye open d. instruct the client to begin reading from the bottom on the chart

a. apical pulse

the nurse is preparing to assess the cardiovascular system of an adult client with emphysema. the nurse anticipates that there may e some difficulty palpating the client's a. apical pulse b. breath sounds c. jugular veins d. carotid arteries

c. maxillary sinuses

the nurse is preparing to examine the sinuses of an adult client. after examining the frontal sinuses, the nurse should proceed to examine the a. ethmoid sinuses b. laryngeal sinuses c. maxillary sinuses d. sphenoidal sinuses

a. position the handle of the otoscope to one side

the nurse is preparing to inspect the nose of adult client with an otoscope. the nurse plans to a. position the handle of the otoscope to one side b. tip the client's head as far back as possible c. direct the otoscope tip quickly back and down the nostril d. position the handle of the otoscope straight and up

c. ask the client to breathe deeply through her mouth

the nurse is preparing to osculates the posterior thorax of an adult female client. the nurse should a. place the bell of the stethoscope firmly on the posterior chest wall b. auscultate from the base of the lungs to the apices c. ask the client to breathe deeply through her mouth d. ask the client to breathe normally through her nose

a. optic chiasma

the optic nerves from each eyeball cross at the a. optic chiasma b. vitreous humar c. optic disc d. visual cortex

b. conduction of the impulse thought the atria

the p-wave phase of an electrocardiogram represents a. conduction of the impulse thought the ventricles b. conduction of the impulse thought the atria c. ventricular repolarization d. ventricular polarization

d. warm the inspired air

the rich blood supply of the nose serves to a. help propel moist air to the body b. propel debris to the throat c. filter large particles from the air d. warm the inspired air

d. soft palate

the roof of the oral cavity of the mouth is formed by the anterior hard palate and the: a. teeth b. gums c. muscles d. soft palate

c. at the exit of each ventricle at the beginning of the great vessels

the semilunar valves are located a. between the left atrium and left ventricle b. between the right atrium and the right ventricle c. at the exit of each ventricle at the beginning of the great vessels d. at the beginning of the ascending aorta

d. posterior wall of the right atrium

the sinoatrial node of the heart is located on the a. anterior wall of the left atrium b. anterior wall of the right atrium c. upper intraventricular system d. posterior wall of the right atrium

c. 7th

the spinous process termed the vertebra prominent is in which cervica vertebra a. 5th b. 6th c. 7th d. 8th

c. Wharton ducts

the submandibular glands open under the tongue through openings called a. parasinal ducts b. stensen ducts c. Wharton ducts d. lacrimonasal ducts

a. meibomian glands

the tarsal plates of the upper eyelid contain a. meibomian glands b. sebaceous glands c. tear ducts d. ocular muscles

a. parietal pleura

the thin double-layed serous membrane that lines the chest cavity is termed a. parietal pleura b. pulmonary pleua c. visceral pleura d. thoracic pleura

b. frenulum

the tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the a. mandible b. frenulum c. gums d. soft palate

d. hypercapnia

under normal circumstances, the strongest stimulus to breath is a. hypoxemia b. hypocapnia c. pH changes d. hypercapnia

a. pneumonia

when asking an adult client's lungs during postoperative period, the nurse detects coarse cracks. the nurse should refer the client to a physician for possible a. pneumonia b. pleuritis c. bronchitis d. asthma

d. refer the client to a physician

when auscultating an adult client's heart rate and rhythm, the nurse detects an irregular pattern. the nurse should a. assess the client for signs and symptoms of pulmonary disease b. document this as a normal finding c. schedule the client for an ECG d. refer the client to a physician

a. cardiac murmur

when plating the apex, left sternal border, and base in an adult client, the nurse detects a thrill, the nurse should further assess the client for a. cardiac murmur b. left-sided heart failure c. constrictor pericarditis d. congestive heart failure

d. infection

while assessing an adult client, the client tells the nurse that she "has had difficultly catching her breath since yesterday". the nurse should assess the client further for signs and symptoms of a. emphysema b. cardiac disease c. trauma to the chest d. infection

c. mitral valve stenosis

while assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. the nurse should refer the client to physician because this is usually indicative of a. pulmonary HTN b. aortic stenosis c. mitral valvue stenosis d. pulmonary hypotension

d. COPD

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 a. atelectasis b. pneumonia c. chest trauma d. COPD

c. associated with occlusive arterial disease

while assessing an older adult client, the nurse detects a bruit over the carotid artery. the nurse should explain to the client that a bruit is a. a normal sound heard in adult clients b. a wheezing sound c. associated with occlusive arterial disease d. heard when the after is almost totally occluded

a. esotropia

while assessing the eye of an adult client, the nurse observes an inward turning of the client's eye. the nurse should document the client's a. esotropia b. strabismus c. phoria d. exotropia

d. corneal reflexes

while assessing the eye of an adult client, the nurse uses a wisp of cotton to stimulate the client's a. eyelid reflexes b. refractory mechanism c. lacrimal reflexes d. corneal reflexes

a. repeat the phrase "night-nine"

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 a. repeat the phrase "night-nine" b. repeat the letter "E" c. whisper the phrase "one-two-three" d. repeat the letter "A"