Health Assessment Test 2 (Chapters 14-19)

The primary muscles of respiration include the:

Diaphragm and intercostals.

The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her sons ears. The nurse would include which of these statements in the teaching plan?

The purpose of the tubes is to decrease the pressure and allow for drainage.

Which of the following is true regarding the vertebra prominens? The vertebra prominens is:

The spinous process

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant?

Maxillary and ethmoid sinuses are the only sinuses present at birth.

A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that:

The girl began to develop breasts.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

The nurse knows that auscultation of fine crackles would most likely be noticed in:

The immediate newborn period.

The nurse is assessing a patient 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?

Black, hairy tongue is a fungal infection caused by all the antibiotics you have received.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

Absence of drainage from the puncta when pressing against the inner orbital rim

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of:

Acquired immunodeficiency syndrome (AIDS).

A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurses best response? Tell the mother that:

Although an examination of her daughter would rule out a problem, her breast development is most likely normal.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

Dark retinal background

A woman in her 26th week of pregnancy states that she is not really short of breath but feels that she is aware of her breathing and the need to breathe. What is the nurses best reply?

What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Wheezes

When assessing a patients lungs, the nurse recalls that the left lung:

Consists of two lobes.

The nurse knows that a normal finding when assessing the respiratory system of an older adult is:

Decreased mobility of the thorax.

The nurse is testing a patients visual accommodation, which refers to which action?

Pupillary constriction when looking at a near object

In a patient who has anisocoria, the nurse would expect to observe:

Pupils of unequal size.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next action should be to:

Recognize that these are serious signs, and contact the physician.

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?

Recognize that this situation requires immediate intervention.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma?Select all that apply.

1) Patient experiences tunnel vision in the late stages. 2) Vision loss begins with peripheral vision. 3) Virtually no symptoms are exhibited.

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply.

1) Progression of hearing loss is slow. 2) The aging person may find it harder to hear consonants than vowels. 3) Sounds may be garbled and difficult to localize.

Which of the following statements is true regarding the internal structures of the breast? The breast is made up of:

Fibrous, glandular, and adipose tissues.

A mother asks when her newborn infants eyesight will be developed. The nurse should reply:

By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

Fifth left intercostal space at the midclavicular line

The primary purpose of the ciliated mucous membrane in the nose is to:

Filter out dust and bacteria.

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Pulling the pinna up and back before inserting the speculum

When listening to heart sounds, the nurse knows that the S1:

Coincides with the carotid artery pulse.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

Enlarged superficial cervical nodes

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?

Pulmonary consolidation

The nurse knows that normal splitting of the S2 is associated with:

Inspiration

During an assessment, a patient mentions that I just cant smell like I used to. I can barely smell the roses in my garden. Why is that? For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. (1) Chronic alcohol use (2) Cigarette smoking (3) Frequent episodes of strep throat (4) Chronic allergies (5) Aging (6) Herpes simplex virus I

(1) Cigarette smoking (2) Chronic allergies (3) Aging

The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply. (1) One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one cigarette. (2) Using SLT has been associated with a greater risk of oral cancer than smoking. (3) Pain is an early sign of oral cancer. (4) Pain is rarely an early sign of oral cancer. (5) Tooth decay is another risk of SLT because of the use of sugar as a sweetener. (6) SLT is considered a healthy alternative to smoking.

(1) Using SLT has been associated with a greater risk of oral cancer than smoking. (2) Pain is rarely an early sign of oral cancer. (3) Tooth decay is another risk of SLT because of the use of sugar as a sweetener.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

Auricle.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

Atelectatic crackles that do not have a pathologic cause.

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?

Avoiding touching the nasal septum with the speculum

During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?

A bifid uvula may occur in some Native-American groups.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

A normal finding in a healthy adult.

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?

It helps equalize air pressure on both sides of the tympanic membrane.

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patients history, the nurse knows that this extra heart sound is most likely a(n):

Atrial gallop.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):

Acute otitis media.

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate?

Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling dry and itchy. Which action by the nurse is correct?

Assessing for other signs of ectropion

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:

Asthma

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?

Air conduction is the normal pathway for hearing.

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?

Allergic rhinitis

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

Anteroposterior-to-transverse diameter ratio of 1:1

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?

Any prolonged exposure to extreme cold

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?

Are you aware of having any allergies?

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

Ask the patient if he or she has a history of heart failure.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

Ask the patient what medications he is currently taking.

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

Bell of the stethoscope at the apex with the patient in the left lateral position.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

Between the scapulae.

The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

Blacks

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:

Blood flow turbulence.

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

Bloody or clear watery drainage can indicate a basal skull fracture.

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for:

Bruising on the buccal mucosa or gums.

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:

Candidiasis.

In performing an assessment of a womans axillary lymph system, the nurse should assess which of these nodes?

Central, lateral, pectoral, and subscapular

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?

Chest pain that is worse on deep inspiration and dyspnea

A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse responds by telling the patient that the middle ear functions to:

Conduct vibrations of sounds to the inner ear.

In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the patients pupils. On the basis of this finding, the nurse would:

Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

Consider this a normal finding.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 oclock in each eye. The nurse should:

Consider this a normal finding.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

Constriction of both pupils occurs in response to bright light.

The nurse is assessing a patients eyes for the accommodation response and would expect to see which normal finding?

Convergence of the axes of the eyes

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

Could be a potential carcinoma, and the patient should be referred for a biopsy.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

Crepitus.

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?

Decreased ability to identify odors

During an assessment of a 20-year-old patient 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:

Dehydration.

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:

Displacement of the heart from elevation of the diaphragm.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?

Does your baby seem to startle with loud noises?

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:

Dullness

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

Hordeolum (stye).

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Dysphagia

When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

Elevates the eyelid and dilates the pupil.

During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):

Enlargement of the right ventricle.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:

Expected near the major airways.

Which statement about the apices of the lungs is true? The apices of the lungs:

Extend 3 to 4 cm above the inner third of the clavicles.

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?

Firm pressure

The nurse is auscultating the chest in an adult. Which technique is correct?

Firmly holding the diaphragm of the stethoscope against the chest.

The tissue that connects the tongue to the floor of the mouth is the:

Frenulum.

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?

Friction rub

A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

Has poor vision.

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be:

Have you noticed any dryness in your mouth?

During a cardiovascular assessment, the nurse knows that an S4 heart sound is:

Heard at the end of ventricular diastole.

During a cardiac assessment on a 38-year-old patient in the hospital for chest pain, the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?

Heart failure

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?

High-tone frequency loss

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:

Hyphema.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Hypomobility

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following?

Hypoventilation

A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, Am I normal? I dont seem to need a bra yet, but I have some friends who do. What if I never get breasts? The nurses best response would be:

I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

Increased density of lung tissue.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

Increased intracranial pressure.

A woman who is in the second trimester of pregnancy mentions that she has had more nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of:

Increased vascularity in the upper respiratory tract as a result of the pregnancy.

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects:

Inflammation of the precordium.

If a patient reports a recent breast infection, then the nurse should expect to find ________ node enlargement.

Ipsilateral axillary

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

Is a characteristic of recruitment.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:

Is a normal finding, and no further follow-up is necessary.

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? Tactile fremitus:

Is caused by sounds generated from the larynx.

When examining the eye, the nurse notices that the patients eyelid margins approximate completely. The nurse recognizes that this assessment finding:

Is expected.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

Is there any relationship between the ear pain and the discharge you mentioned?

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:

Know that floaters are usually insignificant and are caused by condensed vitreous fibers.

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 oclock and landmarks visible. The nurse should:

Know that these are scars caused from frequent ear infections.

During an interview, the patient states he has the sensation that everything around him is spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the:

Labyrinth.

The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is:

Leukoedema and is common in dark-pigmented persons.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

Listen with the bell of the stethoscope to assess for bruits.

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex

During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?

Listening to at least one full respiration in each location

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?

Loss of lens elasticity

The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?

Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have:

Macular degeneration.

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:

Maxillary sinusitis.

A 30-year-old woman with a history of mitral valve problems states that she has been very tired. She has started waking up at night and feels like her heart is pounding. During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with:

Mitral regurgitation.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:

Most likely has serous otitis media.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

Muffled voice sounds and symmetric tactile fremitus.

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?

Murmur at the second left intercostal space when supine

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he cant always tell where the sound is coming from and the words often sound mixed up. What might the nurse suspect as the cause for this change?

Nerve degeneration in the inner ear

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurses response?

No further response is needed because sinus arrhythmia can occur normally.

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings?

No response is needed; this appearance is normal for the tonsils.

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:

Normal for this age.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, I dont know what the matter is. All of a sudden, I cant hear you out of my left ear! What should the nurse do next?

Notify the patients health care provider.

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, It feels like the room is spinning! The nurse notices that the patient is experiencing:

Objective vertigo.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?

Observe the distance between the palpebral fissures.

The nurse is examining a patients retina with an ophthalmoscope. Which finding is considered normal?

Optic disc that is a yellow-orange color

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is:

Otosclerosis.

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

Parallel movement of both eyes

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland.

Parotid

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

Passive cigarette smoke

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

Pearly gray and slightly concave.

The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next?

Perform an otoscopic examination of the left nares.

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:

Perform the otoscopic examination at the end of the assessment.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:

Pneumothorax

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:

Postnasal drip or sinusitis.

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

Presence of bronchovesicular breath sounds in the peripheral lung fields.

When a light is directed across the iris of a patients eye from the temporal side, the nurse is assessing for:

Presence of shadows, which may indicate glaucoma

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?

Presence of small brown macules on the sclera

During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?

Proceed with the assessment, knowing that this appearance is a normal finding.

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, It makes a great pacifier. The best response by the nurse would be:

Prolonged use of a bottle can increase the risk for tooth decay and ear infections.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure?

Pulling the pinna down

During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate?

Pulmonary edema

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?

Rheumatic fever

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infants hearing?

Rubella can damage the infants organ of Corti, which will impair hearing.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

Shadow or diminished vision in one quadrant or one half of the visual field.

When inspecting the anterior chest of an adult, the nurse should include which assessment?

Shape and configuration of the chest wall

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?

Shattered look to the light rays reflecting off the cornea

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurses best response would be:

She is just starting to salivate and hasn't learned to swallow the saliva.

When assessing the pupillary light reflex, the nurse should use which technique?

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison.

Side-to-side

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurses best response?

Sit up with your head tilted forward and pinch your nose.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:

Smooth glossy dorsal surface.

During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:

Sternal angle.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

Stimulated by CNs III, IV, and VI.

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?

Studies show that percussed cardiac borders do not correlate well with the true cardiac border.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?

Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy.

During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?

Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days.

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

Test for color vision once between the ages of 4 and 8 years.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a lazy eye and should:

Test for strabismus by performing the corneal light reflex test.

The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?

Tetralogy of Fallot

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patients abdomen, just below the rib cage?

The jugular veins will remain elevated as long as pressure on the abdomen is maintained.

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:

The location of most breast tumors.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

The normal membrane may appear thick and opaque.

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?

VIII

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? The outer layer of the eye is very sensitive to touch. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

The outer layer of the eye is very sensitive to touch.

A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

The patient can read at 20 feet what a person with normal vision can read at 30 feet.

The nurse is examining a patients ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

The purpose of cerumen is to protect and lubricate the ear.

A 32-year-old woman is at the clinic for little white bumps in my mouth. During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?

These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition.

While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?

These findings can all be normal in a child.

A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother?

This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal.

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurses best response would be:

This is a normal number of teeth for an 18 month old.

During an examination, the patient states he is hearing a buzzing sound and says that it is driving me crazy! The nurse recognizes that this symptom indicates:

Tinnitus.

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?

Tongue that looks smoother in appearance

A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection?

Tonsils 3+/1-4+ with large white spots

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurses preliminary analysis, based on this history, is that this patient may be suffering from:

Tuberculosis

The projections in the nasal cavity that increase the surface area are called the:

Turbinates.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:

Turns his or her head to localize the sound.

The nurse is performing an assessment. Which of these findings would cause the greatest concern?

Ulceration on the side of the tongue with rolled edges

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

Unequal pupillary constriction in response to light

A 17-year-old student is a swimmer on her high schools swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:

Use rubbing alcohol or 2% acetic acid eardrops after every swim.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

Use the Snellen chart positioned 20 feet away from the patient.

During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:

Using these nasal medications irritates the lining of the nose and may cause rebound swelling.

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:

Vesicular breath sounds and normal in that location.

During a cardiovascular assessment, the nurse knows that a thrill is:

Vibration that is palpable.

During an assessment, the nurse notes that the patients apical impulse is laterally displaced and is palpable over a wide area. This finding indicates:

Volume overload, as in heart failure

During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?

Watch the patients respirations while listening for the effect on the sound.

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

When part of the lung is obstructed or collapsed

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

When the bronchial tree is obstructed.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?

When the patient first noticed the lesion

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?

While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Whisper a set of random numbers and letters, and then ask the patient to repeat them.

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest?

Yeast or fungal infection

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

Your sons eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.