Assessment Exam 3 NCLEX Questions
A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?
"Have you taken any antibiotics in the past few weeks?"
What could be indicated by night blindness?
atrophy, glaucoma, or vitamin A deficiency
A client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?
conjunctivitis
When performing the cover test, a nuse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?
exotropia
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
What does blood, purulent discharge from the ears indicate?
otitis media with ruptured tympanic membrane
When the optic disc has blurred margins, what does it indicate?
papilledema or swelling
Which statement reflects accurate documentation by the nurse of a normal, right tympanic membrane?
pearly gray, translucent, with cone of light at 5 o'clock position
Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?
pearly gray, translucent, with cone of light at 7 o'clock position
What action should the nurse implement using an otoscope when assessing the ear of an adult client?
pull the auricle out, up, and back
What could be indicated by contant blind spots?
retinal detachment
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper to his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?
risk for injury
A client with advanced presbycusis admits to the nurse that he was nearly invovled in a car accident because he could not hear the siren of an ambulance that was crossing an intersection through which he was driving. The client says that he lives alone and has no one else to help drive him. Which of the following diagnoses can the nurse make at this time?
risk for injury related to hearing impairment
Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?
touch the cornea with a wisp of cotton
A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition?
"Are the blind spots constant or intermittent?"
What is a stye called? What causes it?
-hordeolum -infection in the lower eyelashes
How do you test the corneal light reflex?
-shine a penligh about 12 inches from their face, directing it towards the bridge of the nose -the reflection of light on the cornea should be in the exact same spot on each eye
What is the Snellen E chart test? When is it used?
-use when the client does not speak English, is unable to read, or has a verbal communication problem -the client is asked to indicate by pointing which way the E is open on he chart
How does a nurse use an ophthalmoscope to examine a client's eye?
-use your right eye to examine the patient's right eye -hold the ophthalmoscope with the index finger on th lens wheel -ask the client to gaze an object striaght ahead and slightly upward -approac the client from the side
Which vision acuity reading
20/200
A nurse performs a Rinne test on a client. What should be the normal finding?
AC (air conduction) greater than BC (bone conduction)
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 performs an inspection and palpation of the auricle when examining the ear or the client. Which documentation by th nurse demonstrates a normal finding?
Darwin's tubercle
A nurse performs a Rinne test on a client who relates a history of decreased hearing in the right ear. The test demonstrates that the client has conductive hearing loss in the right ear. What is the correct documentation of this test by the nurse?
Right: BC (bone conduction) greater than AC (air conduction); left AC greater than BC
A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?
Romberg
How can a nurse accurately assess the distant visul acuity of a client who is non-English speaking?
Use a Snellen E chart to perform the examination
A client tells the nurse that it is difficult to hear normal conversation when in a room wth a lot of noise. Which test should the nurse perform to assess the hearing ability of the client?
Weber
What is the difference between the Weber test and the Rinne test?
Weber: differentiates conduction from sensorineural hearing loss Rinne: compares air and bone conduction
The eyes converging on an object as it is moved towards th nose is a normal result for which test?
accomodation
A client performs the test for ditant visual acuiy and scores 20/50. How should the nurse most accurately interpet this finding?
at 20 feet from the chart, the client sees what a person with god vison can see at 50 feet
What is an infected meibomian gland in the lower lid?
chalazion
A 55-year-old male presents to the health care clinic with reports of decreased hearing over the past year. Which subjective data in the client's review of systems should the nurse recognize as risk factors for hearing loss?
chronic ear infections as a child history of measles at 3 years of age wax blocking th ear canal
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 what structure?
conjunctiva
What type of hearing is the transmission of sound waves through the external and middle ear?
conuctive hearing
A nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal?
corneal light reflex
A nurse performs the cover test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse should observe for which response to indicate a normal finding?
covered eye remains fixed straight ahead
A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots ont he retinal background. The nurse should ask the client about a history of what disease process?
diabetes or hypertension
An elderly client presents to the health care clinic with reports of decreased tearing in both eyes. The nurse observes the presence of ectropion. What is an appropriate action by the nurse?
document the finding as a normal sign of aging
What is the term for when the lower eyelids evert, causing exposure and drying of the conjunctiva?
ectropion
What condition is indicated by pale blue coloration on the auricle of the client's ear?
frostbite
A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?
glaucoma (narrow angle)
What condition is indicated by nontender, hard tophi on the auricle of the client's ear?
gout
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?
have the client hold the Jaeger card 14 inches from the face and read with one eye at a time
Which finding should a nurse recognize as normal when assessing the ears of an elderly client?
high-tone frequency loss
What disease process is indicated by widening of the light reflex with a coppery color to the arterioles and an opaque or silver appearance of the arteriole wall?
hypertension
In what patient would floaters be a common finding?
individuals with myopia or a person over the age of 40 (sign of normal aging)
A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaegar reading card?
instruct the client to hold the chart 14 inches from the eyes
A nurse assesses the distant vision acuity of a client using the Snellen chart. Which action should the nurse implment to perform the test with accuracy?
instruct the client to read without reading glasses
What is myopia vs presbyopia?
myopia = impaired far vision presbyopia = impaired near vision
What does a normal optic disc look like?
orange-colored optic disc that is 1.5 mm wide
What does sticky, yellow discharge from the ears indicate?
otitis externa
What is anothr name for hyperemia of the optic disc due to accumulation of blood?
papilledema
What is gradual sensorineural hearing loss due to degeneration of the cochlea or vestibulocochlear nerve characterized by the inability to hear whispered sounds?
presbycusis
What is the term for impaired near vision?
presbyopia
A nurse examines the ear of a client diagnosed with an obstructed eustachian tube. What finding should the nurse anticipate upon assessment?
prominent landmarks on the tympanic membrane
Which action by the nurse demonstrates correct assessment of the pupillary response and accomodation of a client during an eye examination?
shining a pen light on the eye in a darkened room
A client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test?
six cardinal positions of gaze
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the clint's eyes?
there is no reaction in the opposite pupil to light
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina?
transforms light rays into nerve impulses that are conducted to the brain
In performing an otoscopic examination of a client's tympanic membrane, the nurse observes through the membrane th tip of a landmark at the center of the membrane. Which of the following landmarks is this?
umbo
What could be indicated by intermittent blind spots?
vascular spasm or pressure on the optic nerve
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. What is the technical name for this gelatinous substance?
vitreous humor
A nurse performs an intitial 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
A nurse performs a hearing test on an elderly client. Which result shoul the nurse recognize as an indication that presbycusis is present? An inability to hear:
whispered sounds
A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic disc?
white-colored
What is the term for unequal pupil size?
anisocoria
A client presents to the primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?
brain tumor
Which action by the nurse indicates the approprite use of an ophthalmoscope?
employ the right eye to examine the client's right eye
Which action by the nurse demonstrates correct assessment of the internal structures of the eye of a client during an eye examination?
ophthalmoscope
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?
red, bulging, with an absent light reflex
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for gross peripheral vision?
sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner
What condition is indicated by ulcerated, crusted nodules on the auricle of the client's ear?
skin cancer
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 mother of a 4-year-old asks the nurse when the child will begin to lose his baby teeth. What is the correct repsonse by the nurse?
"Baby teeth will begin to be replaced by permanent teeth about age 6 years."
Which comment during the interview should a nurse recognize as a warning sign that an adolescent is at risk for suicide?
"Books where all the characters die are really cool to read."
During the health assessment interview, which question should the nurse ask the parents of a preschooler to determine the child's level of motor development?
"Can your child run, hop, and skip?"
A nurse is interviewing a client as part of routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?
"Do you experience any ringing, roaring, or crackling in your ears?"
A mother of a 1-month-old calls the health care clinic and tells the nurse that she is concerned because when her infant cries, the top of his head seems to push out. What doestion should the nurse ask the mother to gather more information about this finding?
"Does the bulging stop when the baby stops crying?"
A middle-aged female tells the nurse that she is concerned because her breasts are not as firm as they used to be and asks what might be causing this. What is an appropriate response by the nurse?
"Firmness of the breasts decreases with age as estrogen levels decrease."
An elderly client reports pain the calves. What question is appropriate for a nurse to ask to determine the cause of this pain?
"How far do you walk before you experience pain?"
A mother of a newborn expresses concern to the nurse tht her baby's eyes appear blue but both she and the baby's father have brown eys. How should the nurse respond to the mother's concern?
"Permanent eye color will appear about 9 months of age."
A new mother tells the nurse that the newborn has a small yellow lesion ont he hard palate of the mouth and is worried abou the baby's ability to suck properly. What should the nurse tell the mother about this finding?
"This is common and will disappear within the first few weeks."
An infant is born to a mother who is addicted to cocaine and who used it throughout her pregnancy. Which findings related to this infant's neurologic system should the nurse expect in this infant?
-an inability to quiet to soothing -gaze aversion
A client who recently received breast implants asks for recommendations on performing breast self-examination (BSE). Which of the following should the nurse mention?
-ask the surgeon to help her distinguish the implant from her breast tissue -press firmly inward at the edges of the breast implants to feel the ribs beneath
What factors should the nurse include in a discussion with a young female to assist the client to reduce her risk for breast cancer?
-breast-feed if possible -pregnancy is beneficial before 30 years of age -engage in regular, strenuous physical activity
A nurse is interviewing a 79-year-old client regarding her present health concern. Under whic of the following conditions should the nurse consult a family member of the client to compare he client's current cognition and behavior with a prior level of function?
-client is lethargic and agitated -client appears agitated -client appears excessively distracted -client offers inconsistencies in her respones
When interviewing an school age children, a nurse should keep in mind that this age group has common fears about what type of events in their lives?
-failure at school -staying along -consequences of unattractive appearances
A nurse palpates the breasts of a client for masses during the physical examination. The nurse knows that if a tumor is malignant, which characteristics will be present?
-hard and nontender -fixed to underlying tissues -irregular in shape
What are fibroadenomas?
-lobular, ovoid, or round -firm, well-defined, seldom tender, and usually singular and mobile
A 75-year-old female client is discussing with a nurse changes in her body that have affected her sexual life. Wich of the following should the nurse expect to hear?
-loss of firmness in the labia -increased dryness in the vagina -uterine contractions with orgasm are painful
A 50-year-old female presents to the health care clinic as a new client for a complete physical examination. Which data in her health history should a nurse recognize as a risk factor for the development of breast cancer?
-nulliparity (no pregnancies) -late age at birth of first child (after 30 years old) -late menopause -early menarche
The caretaker of an elderly person tells the nurse that she is worried that the client will shoke because of swallowing problems secondary to a recent CVA. What suggestion should the nurse give the caretaker to minimize the risk of aspiration in the client?
-prepare foods that are pudding consistency or semisolid -encourage client to lean slightly forward and tuck the chin under to prevent gagging
When interviewing an adolescent, a nurse should keep in mind that this age group has common fears about what type of events in their lives?
-relationships of the opposite sex -ability to assume adult roles -drugs -AIDS -divorce -gossip -public speaking -plane and car crashes -homosexual tendencies -death
A nurse assesses an elderly client and determines that the client is at risk for falls. Which interventions are appropriate to reduce the incidence of actual falls the client incurs?
-remind the client to ask for assistance -remove rugs of other loose carpet -assist with exercise to strengthen lower extremities
A nurse is assessing the feet and legs of a child with Down's syndrome. Which of the following findings should the nurse expect in this client?
-short, broard extremities -hyperextensible joints -palmar simian crease
A nurse is inspecting the superficial venous pattern of a nonpregnany client's breasts. Which of the following findings could be an indicator of malignancy?
-veins appearing more prominent -veins appearing in an asymmetric pattern
When does the plantar reflex disappear?
10 months
When does the sucking reflex disappear?
10-12 months
What is the normal heart rate for a newbown?
120 to 160
What is the normal respiratory rate for a child between the ages of 2 and 10?
20 to 28 breaths per minute
A nurse performs a visual acuity test in a 7-year-old client and finds the vision to be normal. What should the nurse document in the client's records?
20/20
A nurse performs a visual acuity test in a 7-month-old client and finds the vision to be normal. What should the nurse document in the client's records?
20/200
A nurse performs a visual acuity test in a 5-year-old client and finds the vision to be normal. What should the nurse document in the client's records?
20/30
A nurse performs a visual acuity test in a 18-month-old client and finds the vision to be normal. What should the nurse document in the client's records?
20/70
What is the normal weight of a newborn?
2500 to 4500 g
What is the normal chest circumference of a newborn?
30 to 33 cm
What is the normal head circumference of a newborn?
33 to 35.5 cm
When does the tonic neck reflex disappear?
4-6 months
What is the normal length of the newborn?
44 to 55 cm
In which anatomic location should the nurse check the apical pulse of an 6-year-old child?
4th intercostal space and at the mid-clavicular line
In which anatomic location should the nurse check the apical pulse of an 3-year-old child?
4th intercostal space and left of the mid-clavicular line
A nurse is assessing a newborn using Apgar scoring. The newborn demonstrates the following: a heart rate of 90 bpm; a good lusty cry; grimaces on irritation; flaccid, limp muscle tone; and a pink body with acrocyanosis. How should the nurse score this client?
5
A nurse is working with an 86-year-old man who has developed pneumonia. The nurse is aware that this clint, due to his age, is living with how much less cellulr function in his organ systems throughout his body than a younger person?
50%
In which anatomic location should the nurse check the apical pulse of an 8-year-old child?
5th intercostal space and right of the mid-clavicular line
A nurse knows that a visual acuity of 20/20 is achieved at what year of age?
6
A nurse understands that the frontal sinuses develop at about what age?
7 to 8
At what year of age should a nurse expect to observe a child's respiratory rate and pattern change to becoem like those of an adult?
8 to 10
A nurse understands that which sleep pattern is considered normal for a school-aged child?
8 to 9 hours of sleep per day
A nurse is working with a client who is considered to be a part of the "frail elderly." At which age is a person typically first considered to be a part of this group?
85
An elderly client calls the health care clinic and asks the nurse if it is ohay to use an OTC nasal spray to help with sinus congestion. WHih question should the nurse ask before assuring the client it is okay to use this medication?
Are you taking any drugs for high blood pressure?
At inspection and palpation of a 16-month-old child's ead, a nurse finds a third fintanelle between the anterior and posterior fontanelle. Which of the following conditions should the nurse most suspect in this client?
Down's syndrome
A nurse examines a frail elderly client's mouth and finds several broken and missing teeth and irritated gums. The nurse should assess this client closely for problems associated with which body system?
GI
A nurse is assessing an elderly client with RA. The nurse observes that the client has difficulty rising from a chair and walking at a normal gait, which the client attributes to painful joitns. The client's pulse rises about 10 bpm on rising and returns to baseline in less than 1 minute. The nurse also learns from th client that she often expriences loss of urine when she laughs, coughs, or sneezes. Which of the following nursing diagnoses can the nurse make based on this information?
Impaired physical mobility
A 26-year-old female presents to the health care clinic for a yearly Pap test and physical exam. She tells the nurse that she has felt a few tender areas in the left breast that are only occasionally palpable. She drinks about 3 cups of coffee daily and an occasional soft drink with caffeine. Family history reveals a maternal aunt with breast cancer at age 75 years. Which nursing diagnosis can be confirmed from this data?
Ineffective Health Maintenance
On inspecting a newborn;s breasts, thenurse notes that they are enlarged ad engorged, with a white liquid discharge. The infant's mother is concerned about it. Which of the following should the nurse tell the mother regarding this finding?
It s due to the influence of the maternal hormones and should resolve in a few days
A nurse would like to asses an elderly client's general functional status in performing daily chores. Which of the following should th nurse implement to make this assessment?
Katz Activities of Daily Living tool
On inspection and palpation, the nurse finds that a client's testes are small, probably less than 2cm and firm. Which of the following conditions should the nurse most suspect in this situation?
Klinefelter's syndrome
A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation?
Mongolian spot
A nurse examines a 6-month-old infant. The persistence of which reflex should the nurse recognize as abnormal?
Moro (startle) reflex
What condition causes red, scaly, and crusty areas over the areola?
Paget's disease
The mother of a newborn has struggled to effectively breastfeed er daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unusual gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion?
RC: hip displacement
What is the Romberg test?
Tests the client's equilibrium, client stands with feet together and arms at sides eyes open and then closed. Client should be able to maintain the position for 20 secs with minimal or no swaying
A nurse is inspecting the anus of a 5-year-old. Which of the following findings should be a cause of concern for the nurse?
a dark ring is present around the anus
How does the nurse assess the Scarf sign?
a nurse should lift the arm acros the chest towards the opposite shoulder until resistance is met
A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern?
a recently retracted nipple that was previously everted
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 touble hearing which of the following in the initial stages of this condition?
a story his wife is telling him
Which action by the nurse demonstrates the correct technique to elicity Ortolani's maneuver?
abduct the legs and move the knees outward
A nurse is working with an elderly client with symptoms of UTI who says she does not like to report health problems and visit the doctor because some of her friends have had negative experiences with clinicians and have even seemed to get worse after doctor's visits. Which of the following interview techniques should the nuse use to encourage the client and build rapport, which will increase the likelihood of her returning for care?
acknowledge the client's exercise habits that have kept her trim and healthy for so long
A nurse recognizes that a most valuable communication tool when working with small children is what technique?
actively engage in play
During the health assessment interview, a nurse should ask the parents of 1-year-old male questons related to which activities to elicit age-related development of psychosexual stage?
activities are centered on expulsion and retention of body waste
Which action by the nurse demonstrates the correct technique to elicity Barlow's maneuver?
adducting the legs until the thumbs of the nurse touch
Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts?
age over 50 exposure to UV B light diabetes mellitus alcohol use cigarette smoking a diet low in antioxidants (eats very few fruits of vegetables) high blood pressure eye injuries (works in lawn maintenance) steroid use
A nurse should implement which important criterion to promote an effective nurse-parent communication when conducting a parent interview as part of the child assessment?
allow privacy for interview, use interpreters is needed, allow adequate time, keep interruptions to a minimum
A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam?
allow the child to place ther hand under the examiner's hand
How can a nurse help to decrease stress and embarassment when examining the external genitalia of a young female child?
allow the child to use her hands to spread the labia
A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?
apical pulse is less than 100 beats per minute
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
A nurse assesses a client's pupils for th reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?
ask the client abou previous trauma to the eyes
Which action by the nurse demonstrates correct assessment of the visual vision acuity of a client during an eye examination?
ask the client to read the Snellen chart
A nurse is inspecting a client's breasts. The nurse notices that one breast is larger than the other. Which action should the nurse take next?
ask the client whether the larger breast has increased in size recently
Upon inspection of an elderly client's ears using an otoscope, the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first?
ask whether the client is experiencing ear pain or pressure
A nurse elicits the plantar grasp reflex in a newborn and notes it to be diminshed. What shold the nurse do in regards to this finding?
assess the newborn for other signs of prematurity
Which assessment parameter should the nurse perform to determine neuromuscular maturity in the baby?
assessment of posture and flexing the elbows to test arm recoil
As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations?
at the center of the client's forehead
On inspection and palpation, the nurse finds that a client's testes are small, probably less than 2cm and soft. Which of the following conditions should the nurse most suspect in this situation?
atrophy
A nurse inspects an elderly client's abdomen and notices the presence of a mass. What is an appropriate action by the nurse in regards to this finding?
auscultate for the rpesence of a bruit
As a part of the ear examination for hearing loss, a nurse conducts a Rinne test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations? Where do the prongs go?
base on the mastoid process and prongs in front of the external auditory canal
A nurse recognizes that what observation is most important to provide clues as to a child's overall health?
behavior
Which action by the nurse demonstrates the correct technique of assessing for the square window sign?
bend wrist toward ventral forearm
An eldergy male client presents to the health care clinic with reports of urinary frequency, nocturia, and difficulty starting his stream. A nurse knows that the most common cause of these symptoms is what condition?
benign prostatic hypertophy
What is an infection of the eyelid by the staphylococcus bacteria?
blepharitis
A nurse prepares a play room for the children in a pediatric nursing unit. The nurse knows that which type of toys is best suited for school-age children?
board games
An elderly client is admitted to the health care facility with an inguinal hernia. Which abnormal data should the nurse expect to find in the client assessment?
bowel sounds heard over scrotum
When assessing the vital signs of a todder, a nurse records normal temperature, pulse, and respiration, but an elevated blood pressure. What is the initial responsibility of the nurse?
check for the size of the cuff
A nurse walks to a mother's room to assess a newborn that is 8 hours old and notices that the hands and feet are cyanotic in appearance. The baby is sleeping but is uncovered on the mother's chest. The nurse recognizes this finding is du to what physiologic occurence?
circulation is decreased because the newborn has been uncovered
Which type of discharge should a nurse consider normal with palpation of the nipples during a breast examination of a nonlactating female client?
clear
A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered, or tightly atached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?
continue with the examination
A nuse auscultates the heart rate in a young child and notes an irregular rhythm. No other abnormal vital signs are present and the child is not in any distress. What is an appropriate action by the nurse in regards to this finding?
count the apical pulse for a full minute to obtain an accurate rate
A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as what abnormal finding?
cystocele
A nurse recognizes that a sudden change in an elderly client's cognition accompanied by a change in the level of alertness may be an indication of what condition?
delirium
What is he term for the separation of the abdominal muscles?
diastasis recti
A nurse is assessing the mobility of the tympanic membran of a 6-year-old client. Which of the following should the nurse do to correctly perform this assessment?
direct a puff of air against the tympanic membrane using a pneumatic bulb
Which finding should cause a nurse concern if found on the interview of a school-age child?
displays difficulty in reading simple sentences
A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nusing action at this time?
document the finding and proceed with the examination
A nurse notes the respiratory rate of a 2-year-old to be 2 breaths per minute. What is an appropriate action by the nurse in regards to this finding?
document the finding in the child's chart
A mother of a preschooler asks the nurse what type of toys will promote the child's development. What should the nurse recommend to this parent?
dress-up clothes
What are some possible causes of sensorineural hearing loss?
dysfunction of cranial nerve VIII, temporal lobe of brain, or organ or Corti
A nurse checks a newborn for the Scarf sign. What should the nurse see if the newborn is full term?
elbow position is less than midline of chest
A nurse inspects the external genitalia of a newborn girl who hs born by breech vaginal delivery. Which of the following findings should be a cause of concern?
enlarged clitoris and fusion of he posterior labia majora
A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding?
enlarged physiologic cup that occupies more than hald of the disc's diameter
What is the term for the presence of a urinary meatus on the dorsal surface of the glans?
epispadiasis
When performing the cover test, a nuse notices that the client's left eye turns inward. How should the nurse document this finding in the client's record?
esotropia
While interviewing a 23-year-old client, a nurse discusses the need for a clinical breast examination (CBE). How often should this client be receiving a CBE?
every 3 years
While interviewing a 42-year-old client, a nurse discusses the need for a clinical breast examination (CBE). How often should this client be receiving a CBE?
every year
Which technique is appropriate for the nurse to use to palpate a client's breast?
flats pads of three fingers
While examining a client's breasts, a nurse notices milky discharge from the nipple. The client explains that she recently had a baby and is currently breastfeeding. The nurse understands that which type of tissue in the breast is responsible for allowing milk production?
glandular
In examining a client's external auditory canal with an otoscope, the nurse discovers impacted ear wax, known as cerumen. Which of the following is characteristic of cerumen? Select all that apply.
has a sticky consistency keeps the tympanic membrane soft has bacteriostatic properties serves as a defense against foreign bodies
When examining the testicles of a young male child, how can a nurse facilitate the exam without eliciting the creasteric reflex?
have the child sit with knees flexed and abducted
A nurse performs, measures, and documents the finding of the initial newborn assessment. Which data should the nurse recognize as an abnormal finding in the newborn?
head circumference is 30 cm
A nurse assesses a 9-month-old with otitis. It is the client's third case in the past 6 months. Otitis media s a risk facto fr which of the following?
hearing loss
A nurse obtains an order to check an elderly client for orthostatic hypotension. Which finding alerts the nurse to a positive result for this test?
heart rate increases 20 beats over the baseline rate
While interviewing a client, the nurse asks her what her typical dialy diet consists of. Which of the following is associated with an increased risk for breast cancer?
high-fat diet
What is the term for the presence of a urinary meatus on the ventral surface of the glans?
hypospadias
A nurse is working with a 14-year-old boy who presents with acne on his face and normal height and weight. He tells the nurse that he eats a fair amount of fast foods, although he is trying to cut down. Which of he following nursing diagnoses can the nurse make based on these findings?
imapired skin integrity
What are some possible causes of conductive hearing loss?
impacted ear wax, otitis media, foreign object, perforated eardrum, drainage in the middle ear, otosclerosis
A nurse inspects the anus a newborn. Which of te following findings should be refered immediately to a specialist?
imperforate anus (no anal opening)
As a nurse is examining a 13-year-old oy, she notices a strong body odor. Which developmental change best explains this finding?
increased apocrine gland activity
A mother brings her 2-month-old infant to the health care facility with a high temperature. Which action by the nuse demonstrates the proper way to safely measure the rectal temperature in the baby?
insert the thermometer no more than 2 cm into the rectum
Which assessment parameter should the nurse perform to determine physical maturity in the baby?
inspect for lanugo (the fine downy hair which disappears afer two weeks of life span)
A nurse is inspecting an elderly client's head and neck. Which of the following findings should most prompt the nurse to suspect onset of a chronic condition?
involuntary facial or head movements
A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining a light obliquely into it. The nurse understands that muscles in which structure adjust to control the amount of light entering the eye through the aperture of the pupil?
iris
A 60-year-old client is concernced about developing cataracts in her eyes. She asks the nurse whether there is anything sh can do to reduce her risk. Consumption of which foods should the nurse recommend to the client for this purpose?
kale, spinach, collards, turnip greens, corn, grean peas, broccoli, romaine lettuce, green beans, eggs, oranges
A nurse working with an 88-year-old client who has developed stress incontinence. In this care, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old?
knowing the person's baseline functional status and recognizing deviations from it
A client presents to the health care clinic with red, watery eyes and constant tearing. The nurse understands that which of the following is the organ that produces tears?
lacrimal gland
A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?
left side-lying
A nurse recognizes that a lsight barrel-shaped chest in an elderly client is due to what physiologic change in the thorax as a result of the aging process?
loss of skeletal muscle strength
What should a nurse expect to hear when auscultating a newborn's heart sounds?
loud, short duration, high-pitched
An elderly client presents to the ED with reports of productive cough of blood-tinged sputum, fatigue, weight loss, and SOB. The nurse recognizes that these are symptoms associated wit whih respiratory disease process?
lung cancer
A nurse measures an 18-month-old child's head circumference (HC) and finds that it is the 96th percentile. Which of the following conditions should the nurse suspect in this child?
macrocephaly
An elderly client states that the right eye has better eyesight than the left. A nurse recognizes that this may indicate the onset of what eye condition?
macular degeneration
During the physical examination of a female client, the nurse notes that the client's axillary lymph nodes are enlarged, hard, and fixed. The nurse recognizes that these findings are consistent with what disease process?
malignancy
What is the order of the bones of the inner ear?
malleus, incus, stapes
A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect?
mastitis
During the breast examination of a client, the nurse notes an orange-peel or "peau d'orange" appearance of the skin of the breast. The nurse understands that this appearance of the skin is due to what type of breast condition?
metastatic disease
A nurse measures an 18-month-old child's head circumference (HC) and finds that it is the 3rd percentile. Which of the following conditions should the nurse suspect in this child?
microcephaly
A nurse recognizes that a priority goal of assessment in the frail elderly is what outcome?
minimize disability associated with illness
Which procedure demonstrates correct placement of a tape measure by a nurse when measuring the chest circumference of a 12-months-old infant?
nipple line
A nurse auscultates the chest of a newborn. The nurse hears breath sounds that are loud and harsh. Which of the following does this finding most likely indicate?
normal
How should a nurse test visual acuity in an infant of 4 weeks of age?
observe the infant's ability to fixate on an object
Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence?
obtain a voiding diary
A nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. The nurse observes the following: painful movement of the pinna and tragus; ear canal is red and swollen with presence of purulent discharge from the external canal; temperature 101.8 F. The mother states that the family was on vacation at the beach last week. The nurse recognzies these findings as an indication of what acute ear condition?
otitis externa
Upon inspection of the external eyes of a child, which position should inidicate to the nurse that the eyes are properly located?
outer canthus aligns with the tip of the pinna of the ear
A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's had. What assessment should the nurse perform next?
palpate the anterior fontanelle
A nurse assesses a 3-month-old infant and finds the foreskin tightened around the glans penis in a retracted position. Which term should the nurse use to document this finding in the medical record?
paraphimosis
What type of hearing is the transmission of sound waves in the inner ear?
perceptive or sensorineural hearing
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
On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasss. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to th face. What should the nurse do next?
perform both the distant and near visual acuity ests
What is the term for unretractable foreskin of the penis?
phimosis
A nurse is discussing breast self-examination (BSE) with a 60-year-old woman. Which of the following should the nurse recommend?
picking a set day of the month that the client will remember on which to perform BSE
What is the term for yellowish nodules on the medial and/or lateral side of the iris?
pinguecula
A nurse assesses the pupilary 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
Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test?
place arms around the client without touching
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for distant visual acuity?
placing the client at 20 feet from the chart and record the smallest line the client can read
What is an appropriate modification in technique that a nurse should take for the examination of the frail elederly client?
plan for additional time to allow as much independence as possible
A nurse prepares a play room for the children in a pediatric nursing unit. The nurse knows that which type of toys is best suited for preschoolers?
play tents and doctor kits
During the health assessment interview, a nurse should ask the parents of 3-year-old male questons related to which activities to elicit age-related development of psychosexual stage?
pleasure is centered on masturbation and genitalia
A nurse assesses a child with a large, irregular, macular patch on the face. What is the correct term that the nurse should use to document tis finding?
port wine stain
A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?
presbyopia
A nonpregnant female presents to the health care facility and reports new onset of breast discharge. The nurse assesses the discharge to be milky in appearance without breast tenderness or masses. What additional data should the nurse obtain from this client?
prescribed medications such as antipsychotic agents (ex. Haldol), hormones, contraceptives
A nurse auscultates the bowel sounds of a 1-month-old. Which of the following findings should warrant further assessment by the nurse?
presence of marked peristaltic waves
How is the palmar reflex assessed in a newborn?
pressing the fingers against the palmar surface of the newborn's hands from the ulnar side
A mother brings her 10-month-old infant to the health care clinic for a routine checkup. Which gross motor developmental task should the nurse expect the infant to be able to have achieved?
pulling self to a standing position with support
A nurse prepares a play room for the children in a pediatric nursing unit. The nurse knows that which type of toys is best suited for toddlers?
push-pull toys
To obtain the most accurate temperature on an infant, a nurse should use which method?
rectal
Which finding in a 6-month-old infant should a nurse recognize as needing further assessment?
reflexively grasps a object (because they should be able to hold an object voluntarily)
During the health assessment interview, a nurse should ask the parents of 9-year-old male questons related to which activities to elicit age-related development of psychosexual stage?
relative sexual indifference and interaction with same-sex peers
When looking at a review of systems for an elderly client, which GI data should cause the nurse the most concern?
reports of constipation
Which assessment data would a nurse expect to find in an elderly client with a pulmonary infection and a productive cough?
respiration more than 25 breaths/min
A nurse inspects the external ears of a 5-month-old infant. The nurse finds low-set ears, with an alignment of about 15 degrees. Which of the following conditions does this finding most likely indicate?
retardation
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
During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process?
retraction of the nipples
A nurse teaches a group of young women about how to properly perform a self breast examination. How should the nurse explain the best time to perform the breast exam?
right after the menstrual flow stops
A simple test that anurse can perform the assess an elderly client's activity tolerance is to ask the client to perform what task while monitoring heart rate?
rise from a chair to a standing position
During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. What reflex is the nurse eliciting from this action?
rooting
A nurse examines a client diagnosed with fibroadenoma. Which characteristic of the lump should the nurse expect to find in the client?
round, firm, well-defined
A nurse observes a newborn's feet and notices thathe right foot is positioned outward. What should the nurse do to further assess this finding?
scratch along the lateral edge of the foot
During the skin assessment of an elederly client, a nurse recognizes that which skin condition is a normal finding?
senile purpura
A nurse performs a "Get Up and Go" test on an elderly client. On completion of the test, the nurse documents the test score is 5. What is the gait assessment result as per the score?
severely abnormal
A nurse should ask a client to assume which position to begin the examination of the breasts?
sitting
A nurse understands that which sleep pattern is considered normal for a preschooler?
sleep 11 to 13 hours per day
A nurse teaches a client about breast self-examination. What should the nurse tell the client about examining the underarm? The arm should be:
slightly raised
A nurse notes the presence of brown, pigmented patches on an elderly client's hands. What is the proper term for the nurse to use to document this finding?
solar lentigines
What is the term for constant malalignment of the eyes?
stabismus
A patient 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
In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record?
stress
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?
the client and the examiner see the examiner's finger at the same time
A nurse performs the Snelled test on a clint and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regrds to th 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
A nurse is observing the throat and tonsils of an 11-year-old girl. Which of the following would represent a noral finding in this client?
tonsils twice the adult size
What should a nurse keep in mind when palpating for the testes in a male infant?
touch or cold may pull the testicles back into the inguinal canal
How is the plantar reflex assessed in a newborn?
touching the ball of the newborn's foot so that the toes curl downwards tightly
A nurse recognizes that which deep tendon reflex is absent in children until the age of 6?
triceps
A mother brings hre 2-month-old infant to the health care clinic because she has noticed a bulge at the umbilicus that seems to be getting bigger when the baby cries. The nurse recognizes this as what type of finding?
umbilical hernia
While interviewing a client, a nurse asks the client whether she has ever noticed any lumps or swelling in the breasts. What other area associated with the possible risk for breast cancer should she ask about regarding the presence of lumps or swelling?
underarm
How should a nurse instruct a client to perform a breast self-examination to most effectively cover the entire breast?
up-and-down pattern starting at the underarm and moving across the breast
A nurse is examining the breasts of a client. In which quadrant should the nurse most expect to find a tumor?
upper outer quadrant
An otherwise healthy elderly client develops sudden onset of confusion, lethargy, anorexia, and nocturia. The nurse should obtain an order for which lab test to assess this sudden change in health status?
urinalyis for the onset of a urinary tract infection
What is an appropriate action by a nurse when asking a child about the presence of pain?
use a pain scale appropriate for the child's developmental level
A nurse is documenting findings for an adolescent client. Which of the following should the nurse do?
use a sequential approach
Which intervention should the nurse suggest to a client to improve the condition of dry skin?
use lanolin-based products
What care should a nurse take to encourage the adolescent to communicate during the health assessment interview?
use open-ended and specific questions
An elderly client reports pain the leg which is not associated with any particular activity but is lessened when the leg is elevated. The nurse recognizes that the client may have which vascular condition?
venous insifficiency
A nurse obtains a blood pressure reading on an 11-month-old infant and finds the reading too high for the age. What is an approprite action by the nurse?
verify that the cuff covers two thirds of the upper arm
A nurse assesses a newborn and finds a white, cheesy substance on the infant's skin, especially within the folds of the skin. How should the nurse document this finding?
vernix caseosa
A nurse should keep in mind what principle of development when interviewing a school-age child?
visual aids will help to explain the process
How should a nurse test visual acuity in an infant of 6 weeks of age?
watch to see if the infant can follow a moving object