prep u

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?"

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?"

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?'

During the physical examination of a client, a nurse notes that the client has tenderness of the breasts. Which question should the nurse ask the client with regard to this finding?

"Are you taking oral contraceptive pills?"

A client tells a nurse that she has been experiencing intermittent episodes of numbness, tingling, pain, and burning in the fingertips, especially after being cold. What is an appropriate question for the nurse to ask the client to further assess this occurrence?

"Do you notice your fingers changing colors?"

The client reports to the nurse that she is concerned she has cancer as she has been experiencing clear discharge from her breasts. What is the best response of the nurse?

"Do you take any medications?"

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?"

A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?

"Hormones affect the severity of migraine headaches."

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."

A hospitalized 70-year-old client with a long history of type 2 diabetes reports a decreased sensation in their lower extremities. What is the best response by the nurse?

"It sounds like you have developed peripheral neuropathy."

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."

A 58-year-old client asks the nurse how often they should have a mammogram. According to the USPSTF Guidelines, what is the best response by the nurse?

"Women 55 and older should have it done yearly."

The nurse is teaching a client about the use of sunscreen. What should the nurse include in the teaching? Select all that apply.

-Apply sunscreen again every 2 hours while in the sun. -Sunscreen should be applied again after sweating or swimming. -Water-resistant sunscreen may be used during activities such as swimming. -Regular use of sunscreen has been found to reduce the incidence of melanoma.

The nurse notes that a client has fibrocystic breasts. What should the nurse expect when assessing this client? Select all that apply.

-Breast pain -Areas of thickening -Green nipple discharge -Changes in breast lumps

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply.

-Cigarette smoking -Previous use of hormones -High-fat diet

Herpes simplex cyst impetigo

-Clustered, fluid-filled vesicles -Lesion that is walled off containing fluid or semisolid material -Bullae that rupture and ooze serous fluid forming a honey-colored crust

The nurse is examining the breast of a clinic client and palpates a lump. What would the nurse be sure to document about this lump? Select all that apply.

-Consistency -Distinctness -Mobility

The client asks the nurse about how to prevent further complications associated with peripheral artery disease. Which modifications should the nurse teach the client? Select all that apply.

-Decrease intake of food high in saturated fat. -Increase physical activity to five times per week. -Decrease blood pressure. -Cease smoking.

What can the nurse recommend to a young female client who is seeking to reduce her risk for breast cancer? Select all that apply.

-Engage in regular, strenuous physical activity -Have children before 30 years of age -Breast-feed if possible

An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply.

-Evaluate the client's outcomes -Modify nursing interventions

What does examination of the skin involve? Select all that apply.

-Inspection -Palpation

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.

-Largest organ of the body -Protects against damage to the body from sunlight -Circulates blood throughout the body -Helps make vitamin D in the body

A community health nurse is providing a teaching session on how to reduce the risks of peripheral vascular disease. What should the nurse include in this session? Select all that apply.

-Reduce intake of sodium. -Participate in regular exercise. -Limit consumption of alcohol to two drinks daily. -Eat a diet high in raw fruits and vegetables daily.right cervical node

A nurse is examining the breasts of a 75-year-old woman. Which of the following are normal findings in the breasts of an older adult? Select all that apply.

-Smaller, flatter nipples -Nipples that are less erectile on stimulation -Pendulous breasts

A nursing instructor is teaching nursing students about hair. Which of the following statements represents the students' understanding of hair? Select all that apply.

-There are two types of hair: vellus and terminal." -"Hair grows on most of the body except some areas such as lips." -"Nasal hair filters dust and other airborne debris."

Which of the following veins drain into the superior vena cava? (Mark all that apply.)

-Upper torso -Head -Upper extremities

A nurse is inspecting the superficial venous pattern of a nonpregnant client's breasts. Which of the following findings could be an indicator of malignancy? Select all that apply.

-Veins appearing more prominent -Veins appearing in an asymmetric pattern

A nurse palpates the breasts of a client for masses during the physical examination. The nurse knows that if a tumor if malignant, which characteristics will be present? Select all that apply.

-hard and nontender -fixed to underlying tissues -irregular in shape

Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person?

1.00

chapter 14

14

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

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+

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+

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

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?

A neuropathic ulcer can develop without feeling it.

A client has Darwin tubercle. What is this?

A small painless nodule on the helix

A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition?

A story his wife is telling him

Which of the following clients is most likely to be diagnosed with migraine headaches?

A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

When assessing the breasts, the client asks why is it important to lift her arms over her head. What is the basis for the nurse's response?

Adds tension to suspensory ligaments

What do retinal abnormalities include?

Age-related macular degeneration

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?

Allen test

What is a long-term complication of peripheral vascular disease?

Amputation

A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition?

Ankle-brachial index (ABI)

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 this condition, common in older adults, as which of the following?

Arcus senilis

During an assessment, the nurse first performs the action shown. After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing?

Arterial insufficiency

The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?

Arterial occlusion

An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?

Arthritis

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background?

Ask permission before palpating the head and neck

A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph nodes .6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the best action of the nurse?

Ask the client if they have experienced any other signs or symptoms.

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

Ask the client to say "aaah"

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead

A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding?

Assess adequacy of blood flow using a Doppler device.

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess the client regarding characteristics of the pain.

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?

Assess the client's blood pressure.

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Assist the client to walk as soon and as often as possible.

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis

A client reports a 2-pack-per-day history of cigarette smoking. To assess this client for cancer, which part of the tongue is it most important that the nurse inspect?

Both sides

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward?

Brachial

A 72-year-old retired saleswoman comes to the office with a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The client denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetrical with no skin changes. The nurse can express bloody discharge from the client's left nipple. No discrete masses are palpable, but her left axilla has a hard 1-cm fixed node. The remainder or her heart, lung, abdominal, and pelvic examinations are unremarkable. What is the most likely cause of nipple discharge in her circumstance?

Breast cancer

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

Bruit

Older adults tend to get arteriosclerosis. What is the cause of this disease process?

Calcification of the arteries

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

Capillary refill greater than 2 seconds

A client presents at the clinic with a chief complaint of right ear pain. The nurse notes a rash in the right ear canal. What should the nurse know is a possible cause of these symptoms?

Chronic otitis media

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

A 48-year-old woman has presented to her primary care provider concerned about the recent detection of a mass in her left breast. The mass is tender on palpation, and the nurse notes that it is round, well-delineated, and mobile. There is no evidence of nipple retraction on inspection. Which of the following breast masses would the nurse first suspect?

Cyst

Which action by a nurse is appropriate to prevent the gag reflex during observation of the uvula?

Depress the tongue slightly off center

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

Deviated septum

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

A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

Inspection of the breast is done with the client in a supine position.

False

The frontal sinuses are the only ones readily accessible to clinical examination.

False

The nurse practitioner is examining a client and notes an axillary lymph node approximately 1.5 cm in size, tender, and movable. The nurse practitioner also notes an erythematous 3-cm abrasion on the client's upper arm. The client tells the nurse practitioner that she fell in the garden while fertilizing her plants. What nursing diagnosis would the nurse practitioner include in the plan of care?

Fear related to possible diagnosis of breast cancer

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?

Firmly compress the lower portion of the varicose vein

A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition?

Fluid collects in the middle ear causing an obstruction of the auditory tube.

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

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?

Graves' disease

A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement?

Headache Impact Test

A nurse is preparing a community education session on hearing loss. Which information should the nurse include?

Hearing loss can contribute to emotional isolation.

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

A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding?

History of breast surgery

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

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

A 77-year-old retired nurse has an ulcer on a lower extremity. All the following diseases are responsible for causing ulcers in the lower extremities except for:

Hypertension

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

Impending stroke

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

In the midline, a few centimeters behind the tip of the mandible

A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left eye noted in the client's medical record supports this diagnosis?

Increased intraocular pressure

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?

Increased thinness

The nursing instructor explains to the students that malignant cells from a breast cancer may spread directly to what nodes?

Infraclavicular nodes

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

Inspect the nostrils with an otoscope

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 hold the chart 14 inches from the eyes

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what?

Intermittent claudication

In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism?

Laboratory tests

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?

Legs should be elevated for 15 seconds

When examining the breasts of a client, the nurse finds a collection of fatty tissue that appears as a lump. The nurse knows that this is which of the following conditions?

Lipoma

The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?

Lymph node

A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client?

Maxillary

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

Medially toward the nose

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

Meibomian glands

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

Migraine

A 56-year-old woman comes to the clinic reporting that her left breast looks unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-breast examinations so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and drinks three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy, but her father died of prostate cancer. Examination shows a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating towards the lateral side. On palpation the nipple feels thickened. Lateral to the areola is a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast examination and axilla are

Nipple retraction

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.

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action?

Observing the eye's reaction when a light is shone into the opposite eye

A nurse is having difficulty palpating a client's dorsalis pedal pulses. What is the best action of the nurse?

Obtain a Doppler ultrasound device.

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth

During the breast examination of a client, the nurse notes red, scaly, and crusty areas over the areola. The nurse understands that this appearance of the skin is due to what type of breast condition?

Paget disease

A 44-year-old woman comes to the clinic complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-breast examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. Examination shows a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath a nontender 2-cm mass is palpable. The axilla contains only soft moveable nodes. The left breast examination and axilla are unremarkable. What visible skin change of the breast does she have?

Paget's disease

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

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

A nurse palpates a weak left radial artery on a client. What should the nurse do next?

Palpate both radial arteries for symmetry.

A mother brings her adolescent son into the clinic because she is concerned about his development of breast tissue. Her son denies use of any medications and is slender in appearance. What should be the nurse's next action?

Palpate for any irregular or hard masses.

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?

Papilledema

Which of the following are the four major axillary node groups?

Pectoral, subscapular, lateral, central

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

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?

Peripheral arterial disease

When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause?

Peripheral arterial disease

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

Peripheral cyanosis

A nurse assesses the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response?

Place an opaque card in between the eyes of the client

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

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

Presbyopia

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

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

Pupillary constriction on near gaze; dilation on distant gaze

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck

The nurse is assessing the left axillae of a client during a breast examination. How should the nurse perform this assessment?

Reach high toward the apex of the axilla with the right hand.

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

Red with loss of papillae

The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion?

Redness and bulging of the eardrum

While conducting a comprehensive assessment on a new client, the client states, "I've had these mouth and tongue sores for a few weeks that do not seem to heal." The nurse assesses the client's mouth and finds thickened lumpy areas with a rough and crusty appearance. What is the best action of the nurse?

Refer the client for further evaluation of the sores.

A nurse is caring for a child with an inner ear infection. The child's mother is worried because the child is having recurrent ear infections and wants to know how the function of the inner ear might be affected. Based on this information, what is the best description the nurse can tell the mother about the function of the inner ear? (Select all that apply.)

Responsible for the transmitting sound waves Responsible for providing information about the body position to the brain

During the physical examination of a client's breast, which finding should the nurse recognize as a possible indication of a malignant tumor?

Retraction of nipples

When inspecting the nipples, which of the following findings is unexpected?

Retraction of the left nipple

During an instruction session on breast self-examination, the nurse would instruct a client to perform the exam at which time?

Right after the menstrual period ends

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

Rinne

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

Skin warm and dry to the touch

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

A client is diagnosed with otosclerosis, a condition in which the auditory ossicles develop a spongy consistency, which results in conductive hearing loss. It appears that the worst site is the inner most bone, which transmits sound waves through the oval window. Which bone is this?

Stapes

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

Stiff neck

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

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.

A nurse is assessing a client's tympanic membrane. The nurse suspects that the client may have otitis media. Which of the following findings would confirm this suspicion?

The membrane does not flutter upon pneumatic otoscopy with a bulb insufflator

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.

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

What are the openings to the middle ear? Select all that apply.

The tympanic membrane The round window The oval window The eustachian tube

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

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.

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

A client diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?

Tinnitus

Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?

Tongue fissures

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

Tonsils are T3

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves?

Trendelenburg test

The radial pulse is palpated over the lateral flexor surface.

True

During an examination of the oral cavity, which technique by the nurse is most likely to improve visualization of the buccal mucosa?

Use a penlight and tongue depressor to retract the lips.

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment

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

Vegetable omelet

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?

Venous insufficiency

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what?

Venous thromboembolism

What pattern of palpation is currently the best validated technique for detecting breast masses?

Vertical strip pattern

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

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

Vitamin deficiency

A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance?

Vitreous humor

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

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

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

The nurse should make it a priority to assess which client for papilledema?

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

acne

Elevated sebaceous glands, known as Montgomery glands, are located in the breast's

areolas.

Recommended protective measures to avoid skin cancer include which of the following?

avoiding sun exposure

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

bulbar portion.

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?

cerebrovascular accident

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?

characteristic symptoms

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the

competence of the saphenous vein valves.

The nurse palpates the top of the client's foot on the side of the great toe. Which artery is the nurse palpating?

competence of the saphenous vein valves.

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.

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

A nurse is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding?

consensual reflexes observed

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

deep vein thrombosis

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis

The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

dermis

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

dermis

A client reports having had difficulty breathing through their right nostril for years. The client denies any other symptoms except for unrestful sleep. The nurse suspects that the client may have which of the following conditions?

deviated septum

The nurse is concerned that a client has undiagnosed cancer of the breast. What assessment finding is most likely related to this clinical determination?

dimpling of the breast

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.

Benign conditions of the breast include

fibrocystic changes

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?

it takes about 6 months

Which of the following assessment findings most likely constitutes a secondary skin lesion?

keloid formation at the site if an old incison

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and explains to the client that there is a genetic component with skin cancer, especially

malignant melanoma

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.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)

notched border diameter great than 6 mm asymmetry

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.

The optic nerves from each eyeball cross at the

optic chiasma.

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

oral mucosa.

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

osteomyletis

During the focused assessment, the client experiences pain when the nurse manipulates (wiggles) the pinna of the ear. Based on these findings, the nurse suspects the client may be experiencing which of the following disorders?

otitis externa

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

preauricular

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.

pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen moisture being allowed to accumulate on the skin

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client?

pustular acne

The nurse is assessing a 50-year-old client's breasts and observes a spontaneous discharge of fluid from the left nipple. The nurse should

refer the client for a cytology examination.

The nurse is caring for a client admitted to the medical surgical unit with neck tenderness, drooling, and dysphagia. In reviewing the orders from the health care provider (see above), which order should the nurse question?

regular diet as tolerated

The nurse plans to instruct an adult female client with regular menstrual cycles, who is not taking oral contraceptives, about breast self-examination. The nurse should plan to instruct the client to perform breast self-examination

right after menstruation.

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

right cervical node

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as

stage ll

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for:

symotoms of stress

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension

A client complains of pain, numbness, and tingling in the upper extremities for several weeks before coming to the clinic for evaluation. What is the nurse's best action?

tension

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

tinea corporis

The nurse observes dimpling in an adult female client's breasts. The nurse should explain to the client that dimpling of the breast may indicate a

tumor.

The nurse instructs a female client on breast self-examination. Which part of the breast should the nurse explain as being the area where most cancers occur?

upper outer

Short, pale, and fine hair that is present over much of the body is termed

vellus

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles

The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as:

vitiligo

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

wheal

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

wood light