Health Assessment Exam 3
The nurse is calling the health care provider about a client's changing condition. Which of the following would be included in the SBAR communication? a) summary, better plan, accurate diagnosis, and rights b) Situation, background, all vitals, and review of orders c) Subjective information, background, assessment, and revisions needed d) Situation, background, assessment, and recommendations
D
A female client comes in to the clinic complaining of perianal itching. Which of the following would NOT be appropriate to assist the client in preparing for a perianal examination? A) Instruct the client to inform you of any pain or discomfort during the exam. B) Assume that the client has had a vaginal exam before and has no questions. C) Ask the client if she would like a family member, friend or chaperone present. D) Have the client empty her bladder.
B
A 60 year old client expresses concerns about his sexual drive. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life can be attributed to: A) Decreased sperm production. B) Side effects of medications. C) Increased sperm production. D) Decreased pleasure from sexual intercourse.
B
A client comes to the clinic complaining of neck and shoulder pain and is unable to turn his head. The nurse suspects damage to cranial nerve (CN)_____ and proceeds with the examination by ________. a) XI; palpating the anterior and posterior triangles b) XI; asking the CLIENT to shrug his shoulders against resistance c) XII; percussing the sternomastoid and submandibular neck muscles d) XII; assessing for a positive Romberg sign
B
A client presents to the ED in acute respiratory distress. How should the nurse proceed with gathering the health history? A) Collect all the information regardless of client condition B) Collect a mini-database and then complete the assessment once the distress is resolved C) Do not collect any information at this time D) Allow rest periods when needed
B
A client states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the client is experiencing: A) dysuria B) stress incontinence C) hematuria D) urge incontinence
B
A client with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the client that the middle ear functions to: a) maintain balance b) interpret sounds as as they enter the ear c) conduct vibrations of sounds to the inner ear d) increase amplitude of sound for the inner ear to function
C
A female client calls out to the nurse stating, "I see spiders on my arm" The nurse suspects the client is displaying symptoms of delirium. Which tool should the nurse use when assessing this client? a) the glasgow coma scale b) The neurologic recheck examination c) the confusion assessment method (CAM) d) the complete neurologic examination
C
A female client tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. The nurse suspects this could be due to dysfunction of which area of the brain? a) Thalamus b) brainstem c) cerebellum d) extrapyramidal tract
C
A nurse is assessing a client recently diagnosed with Parkinson's Disease. What abnormal body movements are typically associated with this disease? a) Myoclonus b) Fasciculations c) Resting tremors d) Tics
C
A nurse is caring for a client whose daughter reports having "behavioral" problems. The nurse knows that the client's change in personality, behavior, emotions, and intellectual function is related to which area of the brain? a) The temporal lobe b) Wernicke's area c) The frontal lobe d) Broca's area
C
An 18-year-old is at the clinic for " a sore throat lasting 6 days." The nurse is aware that which of these findings would be consistent with an acute infection? a) Tonsils 1+/1-4+ and pink, same color as oral mucosa b) Tonsils 2+/ 1-4+ with small plugs of white debris c) Tonsils 3+/ 1-4+ with large white spots d) Tonsils 3+/ 1-4+ with pale coloring
C
During the assessment of THE Biceps reflexes, the nurse finds that a client's responses are normal bilaterally. The nurse would be correct in documenting the finding as ____+ a) 3+ b) 1+ c) 2+ d) 4+
C
All of the following is required equipment you would use for a complete head to toe assessment except: A) Tuning fork B) Platform scale with height attachment C) Stethoscope with bell and diaphragm end pieces D) Hoyer lift
D
At the beginning of rounds, when the nurse enters the room, what should the nurse do first? A) Check the infusion pump settings for accuracy B) Check the intravenous infusion site for redness or swelling C) Offer the client something to drink D) Make eye contact with the client and introduce himself or herself as the client's nurse
D
During an assessment of a 20-year-old client with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: a) a normal oral assessment b) irritation by gastric juices c) side effects from nausea medication d) dehydration
D
In which of the following ways does the electronic health record (EHR) increase client safety? It: A) Decreases transcription and prescribing errors B) Notifies providers of medication interactions C) Means the provider must be physically present on the floor to write orders D) Both A & B
D
The nurse is assessing a client who has a hearing impairment. How should the nurse communicate with this client? a) Use a low tone and speak slowly b) Use a normal tone of voice and speak slowly c) Speak loudly with a normal rate d) Face the client and speak slowly
D
The nurse is assessing the client's position sense by moving the client's fingers and toes in the up, down, and neutral position. The client is able to identify which position the nurse is moving the limbs. The test is called: a) Graphesthesia b) Extinction c) Point location d) Kinesthesia
D
After the health history has been obtained and before beginning the physical examination, the nurse should first ask the client to: A) Empty the bladder. B) Completely disrobe. C) Lie on the examination table. D) Walk around the room.
A
During an assessment of a 20-year-old client with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissure in the tongue. These findings are reflective of: a) dehydration b) irritation by gastric juices c) a normal oral assessment d) side effects from nausea
A
During the history, a client tells the nurse that "it feels like the room is spinning around me." The nurse would document this as: a) vertigo b) syncope c) dizziness d) seizure activity
A
F.A.S.T. is an acronym used as a mnemonic to help detect and enhance responsiveness to stroke victim needs. The nurse recognizes that a correct interpretation of the acronym is: a) F= face drooping, A= Arm weakness, S= speech difficulty, T= Time to call 911 b) F= Feet dropping, A= Arm weakness, S= Speech difficulty, T= time to stroke c) S.T.O.P. S= stop stroke, T= time to rest, O= opt out, P= poke to test d) F= feel the face, A= Arm yourself, S= stop, T= time to rest
A
The nurse is assessing a client who may have hearing loss. Which of these statements is true concerning air conduction? a) It is the normal pathway for hearing b) It is caused by the vibrations of bones in the skull c) The amplitude of sound determines the pitch that is heard d) A loss of air conduction is called a conductive hearing loss
A
A client has been in the hospital for 3 days. The nurse performs a bedside assessment in the morning. In the afternoon the client comes back to the floor after an operation. Which type of assessment would the nurse want to perform? A) Focused assessment B) Complete Head to Toe Assessment C) Functional Assessment D) Bedside Assessment
A
After assessing a client's gait, a nurse has the client stand with his eyes closed to perform the Romberg test in order to assess function of what area of his body? a) cerebellum b) temporal lobe c) spinal cord d) Broca's area
A
The nurse is completing a head to toe assessment on an aging adult client. Which of the following could the nurse do to conserve client energy? A) Arrange the sequence to allow as few position changes as possible B) Rush through the examination C) Complete the examination in one visit D) Maintain a confident manner
A
The nurse is doing an assessment on a 21-year-old client and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the client? a) "Are you aware of having any allergies?" b) "Do you have an elevated temperature?" c) Have you had any symptoms of a cold?" d) "Have you been having frequent nosebleeds?"
A
The nurse is examining an older male client. Which of the following is not an expected change that should be noted? A) loss of libido B) decreased pubic hair C) decreased penis size D) slowed time for erection
A
The nurse is performing an ear examination of an 80-year-old client. Which of these would be considered a normal finding for the aging adult? a) A high-tone frequency loss b) Increased elasticity of the pinna c) A thin, translucent membrane d) A shiny, pink tympanic membrane
A
The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering ear drops. This portion of the ear is called: a) Auricle b) Concha c) outer meatus d) mastoid process
A
The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. a) parotid b) Stensen's c) sublingual d) submandibular
A
The wife of a 65-year-old client tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a) frontal b) parietal c) occipital d) temporal
A
What should the nurse assess before entering the client's room on morning rounds? A) Posted conditions, such as isolation precautions B) The client's input and output chart from the previous shift C) The client's general appearance D) The presence of any visitors in the room
A
What should the nurse assess before entering the client's room on morning rounds? a) Posted conditions, such as isolation precautions b) the client's general appearance c) the presence of any visitors in the room d) The client's input and output from the previous shift
A
When assessing the teeth and gums, which of the following would be a normal finding? a) the teeth are white and the gums are coral pink b) the gums are bleeding c) the adult client has 22 total teeth d) the upper and lower jaw are not aligned
A
Which of the following is true regarding the re-assessment of a hospitalized client? A) It is performed whenever the nurse sees changes in the client B) It is done to give a baseline so that changes can be detected early C) It is a complete head to toe acute care assessment D) Performed once, preferably in the early part of the day
A
Which of the following would be considered subjective data? a) The client states that he has clear discharge coming out of his ears b) you note that the client's ears are equal size and shape c) The client is unable to hear the words on the Whisper Voice Test d) The client's ear drum is a pear gray color
A
Match the following cranial nerves to the function or test used: a)Spinal accessory nerve (CN XII) b) Cranial nerves: III (oculomotor), IV (Trochlear), and VI (Abducens) c) The optic nerve (CN II) d) The acoustic (Vestibulocochlear) Nerve (CN VIII) 1) Diagnostic Positions Test 2) Visual acuity, visual fields, looking in the eyes with an ophthalmoscope 3) Whispered word test 4) Testing range of motion and strength of the neck, shoulder, and head muscles
A&4 B&1 C&2 D&3
A client's wife tells the nurse that she is concerned because she noticed her husband has been having difficulty hearing normal conversation. The nurse suspects the client may have cranial nerve VIII damage. What tests would be appropriate for the nurse to use to confirm suspicions of decreased hearing acuity? (Select all that apply) a) Whisper voice test b) Weber test c) Rinne test d) Romberg test
A, B, & C
Which of the following are coordination and skilled movement assessments used to test cerebellar function? (select all that apply) a) finger-to-finger test b) Stereognosis c) Patting the thighs d) finger-to-nose test
A, C, & D
The nurse is examining an older female client. Which of the following are expected changes that would be noted? Select all that apply A) The vagina is narrow and has lost its elasticity B) The labia & clitoris decrease in size C) Thinning pubic hair D) Decreased sexual drive
A,B, and C
A nurse is conducting a complete neurological exam on a client who reports difficulty with speech. What other questions would be important for the nurse to as this client? (select all that apply) a) when did you first notice this symptom? b) how long did the symptoms last? c) can you describe the symptoms d) any problems forming words?
All of the Above
A nurse is providing a client with information on anal and rectal health. Which of the following should the nurse include in educating the client? Select all that apply A) Avoid straining during defecation B) Eat a high fiber diet C) Avoid lifting extremely heavy items D) Keep anal area clean and dry
All of the Above
A nurse receiving report on a client admitted with symptoms of a stroke asks when the client's symptoms began. She knows this information is important in order to: (select all that apply) a) reduce long term brain damage b) reduce disability c) provide appropriate treatment d) save the person's life
All of the Above
You are caring for a client admitted with c/o dizziness. What questions are appropriate to ask to elicit health history information regarding the client's neuro system? (Select all that apply) a) Do you experience weakness? b) Do you experience numbness or tingling? c) Have you encountered any environmental or occupational hazards? d) Have you ever had a stroke or spinal cord injury?
All of the Above
A graduate nurse asks a more experienced nurse when she should complete a neuro assessment during the course of her shift. An appropriate response would be: a) neuro assessment should not be performed while assessing other body systems b) neuro assessment can be performed covertly c) neuro assessment should only be performed on admission d) neuro assessment should only be performed when a client complains of a headache
B
A nurse is performing an assessment on an uncircumcised male client. She retracts the foreskin and remembers to return the skin to its original position. This action is performed to prevent which of the following from occurring? a) An erection b) Tissue loss c) increased circulation d) hair growth
B
After completing an assessment of a 60 year-old male client with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years.
B
After the health history has been obtained and before beginning the physical examination, the nurse should first ask the client to: a) walk around the room b) empty the bladder c) completely disrobe d) sit in a chair
B
During a neurological assessment, the nurse finds the following: asymmetry when the client smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape or air from one side only when the nurse presses against the puffed cheeks. This would indicate dysfunction of which of these cranial nerves? a) motor component of IV b) motor component of VII c) motor and sensory components of XI d) motor component of X and sensory component of VII
B
During an examination of a 62 year old male, the nurse notices an immobile, tender nodule. A correct assessment of this finding is that this nodule is: A)Normal B) Abnormal
B
In performing a whispered words test to assess hearing, which of these actions would the nurse do? a) Shield the lips so that the sound is muffled b) Whisper a set of random numbers and letters and ask the client to repeat them c) Ask the client to cover both ears simultaneously to occlude outside noise d) Stand about 4 feet away to ensure that the client can really hear at this distance
B
The Glasgow Coma Scale (GCS) is used to measure all of the following functions except: a) Verbal response b) Limb ataxia c) Motor response d) Eye opening
B
The nurse is assessing a client who may have suffered a stroke. Which of these statements is true concerning areas of the brain? a) the cerebellum is the center for speech and emotions b) The hypothalamus controls temperature and regulates sleep c) The basal ganglia are responsible for controlling voluntary movements d) Motor pathways of the spinal cord and brainstem synapse in the thalamus
B
The nurse is assessing a client's visual acuity using the snellen chart. The client's vision is 20/20. This indicates that there is normal function of which cranial nerve? a) Cranial Nerve IV b) Cranial Nerve II c) Cranial Nerve VII d) Cranial Nerve V
B
The nurse is describing how to perform a testicular self-examination to a client. Which of these statements is most accurate? A) "A good time to examine your testicles is just before you take a shower." B) "If you notice an enlarged testicle or a painless lump, call your health care provider." C) "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency." D) "Perform a testicular exam at least once a week to detect the early stages of testicular cancer."
B
The nurse is examining a male client. The client appears apprehensive. Which of the following actions can the nurse employ to reduce the client's anxiety? A) Use a soft, stroking touch B) Be confident and relaxed C) Talk to the client about his sexual practices D) Perform the examination quickly
B
The nurse is palpating the sinus areas. If the findings are normal, then the client should report which sensation? a) No sensation b) Firm pressure c) Pain during palpation d) pain sensation behind they eyes
B
The nurse is performing a neurological assessment on a 60 year old client who suffered a stroke and is experiencing left-sided weakness. She asks the client to stick her tongue out and move ti from side to side. The nurse notes the client's tongue deviates to the left side and suspects damage to which cranial nerve? a) Cranial nerve IX b) Cranial nerve XII c) Cranial nerve VIII d) Cranial Nerve V
B
The nurse is performing a peripheral assessment of a female client and notes copious, foul-smelling vaginal discharge. A correct assessment of this finding is that this is: a) A Pilonidal cyst b) A vaginal infection c) Carcinoma d) Poor hygiene
B
The primary purpose of the ciliated mucous membrane in the nose is to: a) warm the inhaled hair b) filter out dust and bacteria c) filter coarse particles from inhaled hair d) facilitate movement of air through the nares
B
What is an advantage for using the SBAR during staff communication? A) Provides a complete client health history B) Improves verbal communication and reduces medical errors C) Focuses on a comprehensive physical examination D) Avoids making recommendations
B
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: a) light pink with a slight bulge b) pearly gray and slightly concave c) pulled in at the base of the cone of light d) Whitish with small fleck of light in the superior portion
B
Which of the following behaviors demonstrated by an individual may be indicative of hearing loss? a) not looking at the examiner when being questioned b) frequently asking for the question to be repeated c) talking in a high-pitched voice d) speaking slowly with well-articulated consonants
B
Which of the following is a true statement regarding the bedside assessment of the hospitalized client? A) Hospitalized clients require a complete head to toe screening exam every 24 hours B) The bedside assessment is a specialized assessment done at least every 12 hour shift C) The bedside assessment is the complete examination done with the first client encounter D) The bedside assessment only focuses on one body system
B
Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the client.
B
A client was admitted to the ED with slurred speech. The nurse notes that this could be due to dysfunction of what cranial nerve(s)? a) cranial nerve I b) cranial nerve V c) cranial nerves IX and X d) cranial nerve III
C
Which of the following are expected changes that can be seen in the older adult due to the loss of neurons in the brain and spinal cord limitation? (select all that apply) a) improvement in fine coordination and agility b) decreased muscle strength and agility c) decreased reaction time d) Progressive decrease in cerebral blood flow
B, C, & D
A nurse is performing an assessment on an uncircumcised male client. She retracts the foreskin and remembers to return the skin to its original position. This action is performed to prevent which of the following from occurring? Select all that apply A) An erection B) Tissue loss C) Decreased circulation D) Amputation
B,C, and D
A 92-year-old client has had a stroke. the right side of his face is drooping. The nurse might also suspect which of these assessment findings? a) Epistaxis b) Rhinorrhea c) Dysphagia d) Xerostomia
C
A client has been shown to have sensorineural hearing loss. During the assessment, it would be important for the nurse to: a) speak loudly so he can hear the questions b) assess for middle ear infection as a possible cause c) ask the client what medications he is currently taking d) look for the source of the obstruction in the external ear
C
A client tells the nurse he is having numbness on the left side of his face. the nurse asks him to close his eyes and touches a cotton ball to his forehead, chin, and both cheeks. The nurse is testing the function of which cranial nerve? a) cranial nerve III b) cranial nerve IV c) cranial nerve V d) cranial nerve VII
C
During the interview, a client reveals to the nurse that she has been having a large amount of vaginal discharge and itching. She is worried that it may be a sexually transmitted infection. An appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"
C
The nurse is assessing a client in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a) "We will need to get a biopsy and see what the cause is" b) "This is an overgrowth of hair and will go away in a few days" c) "This is a fungal infection caused by all the antibiotics you've received." d) "This is probably caused by the same bacteria you had in your lungs"
C
The nurse is assessing an 80-year-old client. Which of these findings would be expected for this client? a) hypertrophy of the gums b) an increased production of saliva c) a decreased ability to identify odors d) Finer and less prominent nasal hair
C
The nurse is assessing the ear of an adult client. How should the nurse perform the examination? a) Pull the pinna down and insert scope b) Insert the scope straight into the ear c) Pull the pinna up and back and insert the scope d) Tilt the scope to the angle of the ear
C
The nurse is examining a client's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a) Sticky honey-colored cerumen is a sign of infection. b) the presence of cerumen is indicative of poor hygiene c) The purpose of cerumen is to protect and lubricate the ear d) cerumen is necessary for transmitting sound through the auditory canal.
C
The nurse is inspecting a female client's perianal area. Which of the following assessment findings, if noted, would be considered abnormal? A) Smooth and even colored sacrococcygeal area B) Dark pink colored labia minora C) Excoriation, inflammation or swelling D) Moist, hairless anus
C
The nurse is performing an oral assessment and asks the client to stick out his tongue and say "ahh." She notes that his uvula deviates to one side. She suspects there may be damage to which cranial nerve? a) Cranial Nerve IX b) Cranial Nerve XII c) Cranial Nerve X d) Cranial Nerve VII
C
The nurse is teaching a male client the best way to perform a testicular self-examination. Which of these statements best describes the correct information? a) "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency" b) "A good tie to examine your testicles is just before you take a shower" c) "If you notice an enlarged testicle or a painless lump, call your health provider" d) "Perfrom a testicular exam at least once a week to detect the early stages of testicular cancer."
C
The salivary gland that is the largest and located in the cheek in front of the ear is the ________________ gland. a) Stensen's b) sublingual c) parotid d) submandibular
C
The two sinuses that can be directly palpated are? a) frontal and sphenoid b) maxillary and ethmoid c) frontal and maxillary d) ethmoid and sphenoid
C
When completing a physical assessment of all body systems on an older adult with mobility problems, the sequence should: a) be from head to toe to prevent missing any important assessments b) Begin with the physical examination followed by the health history c) be arranged to minimize the number of position changes for the client and the examiner d) start with the most invasive assessments
C
When observing the left tympanic membrane of a patient with an otoscope, the examiner notices the cone of light (light reflex) is at 7 o'clock. The examiner suspects: a) perforation from a ruptured membrane b) abnormal wax build-up c) this is a normal tympanic membrane d) a fungal infection
C
Which of the following statements is true regarding the olfactory nerve (CN I)? a) the olfactory nerve is tested by having the client shrug their shoulder b) The olfactory nerve is tested by having the client say "light, tight, dynamite" c) The olfactory nerve is tested by having the client smell a familiar substance like coffee, lemon, or vanilla d) The olfactory nerve is tested by having the client stick the tongue out
C
Which of the following would not be appropriate to assist a female client in preparing for a vaginal examination? a) Ask the client if she would like a family member, friend, or chaperone present b) instruct the client to inform you of any pain discomfort during the exam c) Assume that the client has had a vaginal before and has no questions d) have the client empty her bladder
C
A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" A correct response would be: A) "It depends. Do you smoke?" B) "A Pap test needs to be performed annually until you are 65 years of age." C) "If you have two consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30, if you have three consecutive normal Pap tests, then you may be screened every 3 years."
D
A 75 year old client with an enlarged prostate is concerned because he has trouble sleeping. He states, "I have to pee about 6 or 7 times a night and it just drips." A correct response would be: A) "You probably have a bladder infection. We'll need to give you antibiotics." B) This is a natural part of the aging process." C) "This is the way the kidney removes bacteria from the body." D) "You may want to cut back on drinking fluids about 3 hours before bedtime."
D
A female client has just been diagnosed with Human papillomavirus (HPV) and genital warts. The nurse should counsel her to receive regular examinations because this virus places her at a higher risk for which disease process? A) Bladder Infection B) Uterine Prolapse C) Ovarian Cysts D) Cervical Cancer
D
A female client is in the clinic with weakness in her left arm and leg that she has noticed for the past week. Which type of neurologic examination would be most appropriate for this client? a) Glasgow Coma Scale b) Neurologic Recheck examination c) Neurologic Screening Examination d) Complete Neurologic Examination
D
A new graduate nurse asks a more experienced nurse why the initial assessment is done in the early part of the day. The nurse would respond: A) To get your charting done before the physician rounds B) To assess a client following procedures C) To have a more accurate assessment D) To get a baseline for your client so that changes can be detected early
D
The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report? A) "I'm worried that his gastrointestinal bleeding is getting worse." B) "We need an order for oxygen." C) "My name is Ms. Smith, and I'm giving the report on Mrs. X in room 1104." D) "He is 4 days postoperative, and his incision is open to air."
D
The nurse is performing an assessment of a male client. Which of these statements is true about the testes? A) The lymphatics of the testes drain into the abdominal lymph nodes. B) The vas deferens is located along the inferior portion of each testis. C) The right testis is lower than the left because the right spermatic cord is longer. D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body.
D
The nurse is taking the history of a client who may have a perforated eardrum. What would be an important question in this situation? a) "Do you ever notice ringing or crackling in your ears?" b) "When was the last time you had your hearing checked?" c) "Have you ever been told you have any type of hearing loss?" d) "Was there any relationship between the ear pain and the discharge you mentioned?"
D
The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The client: a) demonstrates ability to hear normal conversation b) Sticks tongue out midline without tremors or deviation c) follows an object with both eyes without nystagmus or strabismus d) moves the head and shoulders against resistance with equal strength
D
The nurse is using the diagnostic positions test to assess her client's extraocular eye movements. She notes parallel tacking of both eyes. She would be correct in documenting normal findings for which cranial nerve(s)? a) Cranial Nerve VII b) Cranial Nerve I c) Cranial NerveII d) Cranial Nerves III, IV & VI
D
The nurse suspects that her client may have suffered a stroke. Which tools can the nurse use to confirm her suspicions? a) R.A.C.E. b) NIH Scale c) F.A.S.T. d) Both b and c
D
When assessing the hypoglossal nerve (CN XII), the nurse looks at and tests: a) symmetry of facial features b) the uvula rising to the midline when a person says "Ah" c) Full, sustained eye opening d) Movement and strength of the tongue
D
Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X (Vagus)? a) Observe the client's ability to articulate specific words. b) Observe the client's ability to move the shoulders against resistance c) Have the client stick out the tongue and observe for tremors or pulling to one side d) Ask the client to say "ahhh" and watch for movement of the soft palate and uvula
D
