Nursing Assessment and Skills Quiz II Practice Questions

A patient tells the nurse that he has smoked 1 packs of cigarettes a day for 14 years. The nurse records this as _____ pack-years?

14

What instruction does a nurse give a patient to facilitate palpation of the right lobe of the thyroid gland? a. Swallow for me one time. b. Flex your head down and to the left. c. Rotate your head to the right for me. d. Hold your breath for a few seconds.

a

What signs of cyanosis does a nurse inspect for in a dark-skinned patient? a. Ashen-gray color of the oral mucous membranes b. Blue color in the nail beds c. Ashen-blue color in the palms and soles d. Blue-gray color in the ear lobes and lips

a

A nurses presentation to patients on risk factors for macular degeneration includes which fact? a. The peak incidence is before 60 years of age. b. Women have a higher risk than men. c. Eating a low fat diet causes a vitamin A deficiency, which increases risk. d. Cigarette smokers have twice the risk as nonsmokers.

d

When inspecting a patients eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve? a. Pupillary constriction to light b. Visual acuity c. Peripheral vision d. Presence of the red reflex

a

When inspecting a patients nasal mucous membrane, which finding does the nurse expect to see? a. Deep pink turbinates b. Red, edematous mucous membranes c. Septum that angles to the left d. Clear exudate

a

When the patients chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? a. Purplish-red pinpoint lesions b. Deep purplish or red patches of skin c. Small raised fluid-filled pinkish nodules d. Generalized reddish discoloration of an area of skin

a

A nurse examines a patients auditory canal and tympanic membrane with an otoscope and observes which finding as normal? a. Clear fluid lining the auditory canal b. A firm tympanic membrane without fluctuation with puffs of air c. A small hole within the cone of light d. A shiny, translucent tympanic membrane

d

During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data? a. Does the sputum have an odor? b. Do you have chest pain when you take a deep breath? c. Have you also experienced tightness in your chest? d. Have you coughed up any blood?

a

On palpation the nurse determines that the patients left thyroid lobe is larger than the right thyroid lobe. What is the nurses most appropriate action at this time? a. Refer the patient to the health care provider for further evaluation. b. Document that the patients thyroid is normal on palpation. c. Palpate the left thyroid lobe again using very firm pressure. d. Ask the patient to flex the chin toward his chest and palpate again.

a

A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patients lungs? a. Vesicular breath sounds heard in peripheral lung fields b. Bronchial breath sounds heard over the bronchi c. Bronchovesicular breath sounds heard over the apices d. Rhonchi heard over the main bronchi

a

A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of healing. What is the most appropriate action for the nurse at this time? a. Obtain further data now to rule out abuse. b. Remind parents that toddlers are clumsy and may fall, causing bruising. c. Determine if this toddler has a coagulation disorder. d. Recommend further observation at future visits.

a

A nurse notices a patients chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately? a. Palpate for tracheal deviation. b. Auscultate for bronchovesicular breath sounds in the lung periphery. c. Palpate posterior thoracic muscles for tenderness. d. Auscultate for absence of breath sounds in the lung periphery.

a

A nurse notices a patients nails are thin and depressed with the edges turned up. What additional abnormal data should the nurse expect to find on this patient? a. Pale conjunctiva b. Jaundice c. Ecchymosis d. Rashes

a

A nurse notices several reddish purple, nonblanchable spots of different sizes on the arms and legs of a patient with a low platelet count. How does the nurse distinguish ecchymosis from purpura? a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. b. Ecchymosis does not blanch and purpura does blanch. c. Ecchymosis has raised lesions and purpura has flat lesions. d. Ecchymosis is irregularly shaped and purpura is round.

a

A nurse shines a light toward the bridge of the patients nose and notices that the light reflection in the right cornea is at the 9 oclock position and in the left cornea at the 9 oclock position. What is the interpretation of this finding? a. The extraocular muscles of both eyes are intact. b. The cornea of each eye is transparent. c. The sclera of each eye is clear. d. The consensual reaction of both eyes is intact.

a

A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patients nares? a. Clear b. Malodorous c. Yellow d. Green

a

A patient has come to the clinic complaining of a bump behind his right ear. Upon inspection, the nurse notes a lesion that is elevated, solid, and 4 cm in diameter. What does the nurse call this lesion when she reports her findings to the health care provider? a. Tumor b. Nodule c. Keloid d. Papule

a

A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation? a. Bronchophony reveals the patients spoken 99 as clear and loud. b. No sounds are expected since sounds cannot be transmitted through consolidation. c. Egophony reveals indistinguishable sounds when the patient says e-e-e. d. Whispered pectoriloquy reveals a muffled sound when the patient says 1-2-3.

a

A patient is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis? a. Unilateral foul-smelling drainage b. Bilateral purulent green-yellow discharge c. Bilateral bloody discharge d. Unilateral watery discharge

a

A patient reports having migraine headaches on one side of the head that often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient reports which associated symptoms of migraine headaches? a. Nausea, vomiting, or visual disturbances b. Nasal stuffiness or discharge c. Ringing in the ears or dizziness d. Red, watery eyes or drooping eyelids

a

After assessment of the nose and paranasal sinuses, which finding requires further investigation by the nurse? a. Nasal septum off the midline b. Nose in the midline of the face c. Middle turbinates deep pink in color d. Noiseless exchange of air from each naris

a

After taking a brief health history, a nurse needs to complete a focused assessment on which patient? a. A male who works as a painter b. A male who plays basketball and hockey c. A female who recently moved into a college dormitory d. A female who has a history of gout

a

An adult patient comes to the clinic complaining of right ear pain. What technique does the nurse use to inspect this patients auditory canal? a. Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal. b. Remove cerumen from each canal before inserting otoscope. c. Choose the smallest otoscope speculum that will fit the patients ear comfortably. d. Pull the pinna slightly downward and backward before inserting the otoscope speculum.

a

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness? a. I felt faint, like I was going to pass out. b. It felt like I was on a merry-go-round. c. The room seemed to be spinning around. d. My body felt like it was revolving and could not stop.

a

During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares? a. Enlarged and pale turbinates b. Polyps within the nares c. High vascularity of the turbinates d. Dry and dull turbinates

a

When using an ophthalmoscope to examine the internal eye, how does the nurse distinguish the retinal arteries from the retinal veins? a. The arteries are narrower than veins. b. The arteries are a darker red than veins. c. The arteries have no light reflex and the veins have a narrow band of light in the center. d. The arteries have prominent pulsations and veins have no pulsations.

a

Which cranial nerve is assessed by using the Snellen visual acuity chart? a. Optic cranial nerve (CN II) b. Oculomotor cranial nerve (CN III) c. Abducens cranial nerve (CN IV) d. Trochlear cranial nerve (CN VI)

a

Which finding indicates that this patient has a sensorineural hearing loss? a. The patient hears sound by air conduction longer than by bone conduction. b. The patient hears sound from a vibrating tuning fork in the affected ear only. c. The patient hears normal conversation at 40 dB and a whisper at 20 dB. d. The patient hears the rubbing of fingers together from a distance of 4 inches from each ear.

a

Which patient should the nurse assess first? a. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right. b. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever. c. The patient who is short of breath, using pursed-lip breathing, and in a tripod position. d. The patient whose respiratory rate is 20 breaths/min, and has 8-word dyspnea and expiratory wheezes.

a

While giving a history, a patient reports itching arms, legs, and chest after using a new soap. What manifestations does the nurse expect to find on the arms, legs, and chest when inspecting this patients skin? a. Elevated irregularly shaped areas of edema of variable diameter b. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameter c. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with serous fluid d. Elevated, firm circumscribed areas less than 1 cm in diameter

a

On examination, a nurse finds the patient has a productive cough with green sputum and inspiratory crackles. What other findings does this nurse expect during the examination? Select all that apply. a. Dull tones to percussion b. Increased vibration on vocal fremitus c. Fever d. Decreased diaphragmatic excursion e. A sharp, abrupt pain reported when patient breathes deeply f. Muffled sounds heard when the patient says e-e-e

a, b, c, e

Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply. a. Lips appear pink, smooth, moist, and symmetric b. Teeth are white, yellow, or gray, with smooth edges c. Exposed tooth neck and brown spots between teeth d. Slight roughness on the dorsum of the tongue e. Hard palate appears smooth, pale, and immovable f. Mucous membranes are dry and intact

a, b, d, e

Nurses inquire about lifestyle behaviors in those patients with specific risk factors for cataracts. Which characteristics are associated with risk factors for cataracts? Select all that apply. a. Smoking more than 20 cigarettes a day b. Having parents with cataracts c. Chronic consumption of alcohol d. Having a chronic disease, such as diabetes mellitus e. Being Asian f. Being a man

a, c, d

What are the functions of the upper airways? Select all that apply. a. Conduct air to lower airway. b. Provide area for gas exchange. c. Prevent foreign matter from entering respiratory system. d. Warm, humidify, and filter air entering lungs. e. Provide transportation of oxygen and carbon dioxide between alveoli and cells.

a, c, d

Which questions are appropriate to ask a patient when performing a symptom analysis for a rash? Select all that apply. a. When did the rash first start? b. Do you have a family history of rashes? c. What makes the rash worse? d. What do you do to make your rash better? e. Describe the sensation from the rash, does it burn or itch? f. Describe what the rash looked like initially.

a, c, d, e, f

A nurse is assessing the eyes of a healthy 72-year-old adult. What findings does the nurse expect? Select all that apply. a. Bulbar conjunctiva pink and clear, with small red vessels noted b. Sclera yellow and moist, cornea transparent c. Extraocular movement symmetric with peripheral vision noted d. Newspaper held at 18 inches to see clearly e. Sclera visible between upper lid and iris f. Gray to white circle noted where the sclera merges with the cornea g. Light reflects on the cornea at 12 oclock in each eye

a, c, g

A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? Select all that apply. a. Thoracic expansion that is symmetric bilaterally b. Respiratory rate of 24 breaths/min c. Bronchophony revealing clear voice sounds d. Breath sounds clear with vesicular breath sounds heard over most lung fields e. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter f. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine

a, d, e, f

What findings does the nurse expect when assessing the ears of a healthy adult? Select all that apply. a. Cerumen noted in the outer ear canal b. Pinna located below the external corner of the eye c. Cone of light located in the 5 oclock position in the left ear d. Ratio of air conduction to bone conduction 2:1 e. Tympanic membrane pearly gray f. Whispered words repeated accurately

a, d, e, f

A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a. Yellowish color in the axilla and groin b. Yellow pigmentation in the sclera c. Very pale skin on the palms d. Ashen-gray color in the oral mucous membranes

b

A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for hearing? a. Bone conduction will be longer than air conduction on the Rinne test (BC > AC). b. Air conduction will be longer than bone conduction on the Rinne test (AC > BC). c. Sound lateralizes to the affected ear on the Weber test. d. Sound lateralizes to both ears equally on the Weber test.

b

A nurse auscultates low-pitched, coarse snoring sounds in a patients lungs during inhalation. What is the most appropriate action for the nurse to take at this time? a. Palpate the posterior thorax for vocal fremitus. b. Ask the patient to cough and repeat auscultation. c. Auscultate the posterior thorax for vocal sounds. d. Percuss the posterior thorax for tone.

b

A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patients integumentary system, what finding should the nurse correlate to this respiratory disease? a. Dry, flaky skin b. Clubbing of the fingers c. Hypertrophy of the nails d. Hair loss from the scalp

b

A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection? a. Tinnitus, vertigo, and dizziness b. Clear drainage from the ear and nose c. Loss of hearing and smell d. Purulent drainage from the ear and bloody drainage from the nose

b

A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? a. Make sure the bell of the stethoscope is used, rather than the diaphragm. b. Hold stethoscope firmly to prevent movement when placed over chest hair. c. Ask the patient not to talk while the nurse is listening to the lungs. d. Change the patients position to ensure accurate sounds.

b

A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings. How will the nurse recognize the characteristics of keloids? a. Roughened and thickened scales involving flexor surfaces b. Hypertrophic scarring extending beyond the original wound edges c. Thin, fibrous tissue replacing normal skin following injury d. Loss of the epidermal layer, creating a hollowed-out or crusted area

b

A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patients left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage? a. Stage I b. Stage II c. Stage III d. Stage IV

b

A nurse notices multiple lesions on the back of a patients left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. How does the nurse document these lesions? a. As multiple macules on the dorsum of the left hand b. As multiple vesicles on the dorsum of the left hand c. As several patches on the left hand d. As several bullae on the dorsum of the left hand

b

A nurse notices that the angle of the patients proximal nail fold and the nail plate are almost a flat line; about 160 degrees. How does the nurse interpret this finding? a. This patient has chronic pulmonary disease. b. This is an expected finding. c. This is due to stress to the nails. d. This is associated with anemia.

b

A nurse observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the student requires a corrective comment from the nurse? a. Instructing the patient to cover the ear not being tested b. Standing beside the patient on the side of the ear being tested c. Shielding the mouth to prevent the patient from reading lips d. Whispering one or two syllable words and ask the patient to repeat what is heard

b

A nurse shines a light toward the bridge of the patients nose and notices that the light reflection in the right cornea is at the 2 oclock position and in the left cornea at the 10 oclock position. Based on these data, the nurse should take what action? a. Document these findings as normal. b. Perform the cover-uncover test. c. Perform the confrontation test. d. Document these findings as abnormal.

b

A nurse suspects a patient has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use? a. Place the palmar side of each hand against the lateral thorax at the level of the waist, ask the patient to take a deep breath, and observe lateral movement of the hands. b. Place both thumbs on either side of the patients T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs. c. Place both thumbs on either side of the patients T7 to T8 spinal processes, extend fingers laterally, ask the patient to exhale deeply, and observe lateral inward movement of the thumbs. d. Place the palmar side of each hand on the shoulders of the patient, ask the patient to sit up straight and take a deep breath, and observe symmetric movement of the shoulders.

b

A patient asks the nurse if it is possible to grow new skin. What is the nurses most appropriate response? a. Even if new skin growth is required, the melanocytes do not regenerate. b. The avascular epidermis sheds slowly and is replaced completely every 4 weeks. c. The outer layer of skin remains the same over the lifetime except for repairing injuries. d. Epidermal regeneration is impossible because it is avascular.

b

A patient complains of a lesion in his nose. Which technique does a nurse use to inspect the nasal mucosa? a. Inserts a nasal speculum horizontally into the patients affected nares b. Inserts a nasal speculum obliquely into the patients affected nares c. Uses a light source from the ophthalmoscope d. Inserts a nasal speculum vertically into the patients affected nares

b

A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination? a. Foul-smelling drainage b. Purulent green-yellow drainage c. Bloody drainage d. Watery drainage

b

A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma? a. Nonblanching lesion b. Irregular border c. Diameter less than 5 mm d. Black color of the lesion

b

A patient has had an infected facial wound for more than 3 months. How does the nurse expect the patients enlarged lymph nodes to feel? a. Soft, edematous, and tender b. Round, tender, and movable c. Hard, nontender, and nonmobile d. Irregularly shaped, tender, and firm

b

A patient is admitted with edema of the occipital lobe following a head injury. The nurse correlates which finding with damage to this area? a. Ipsilateral ptosis b. Impaired vision c. Pupillary constriction d. Increased intraocular pressure

b

A patient is suspected of having a lung consolidation. A nurse uses the three techniques for assessing vocal resonance in this patient. What is the expected finding among the three procedures that will help eliminate consolidation as a problem? a. The nurse documents clearly hearing the patient say 99. b. The nurse documents hearing muffled sounds when the patient says 1-2-3. c. The nurse documents hearing no sounds when the patient says e-e-e. d. The nurse documents clearly hearing the patient say a-a-a.

b

A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate on examination? a. Decreased breath sounds on auscultation b. Increased tactile fremitus and dull percussion tones c. Inspiratory wheezing found on auscultation d. Muffled sounds heard when the patient says e-e-e

b

A teenager comes to the clinic complaining about the whiteheads and blackhead on his face interfering with his social life. During the examination the nurse palpates an enlarged submental lymph node. Where is this lymph node located? a. In front of the ear b. Under the mandible c. At the base of the skull d. Along the angle of the jaw

b

After seeing the red reflex and retinal vessels through the ophthalmoscope, how does the nurse locate the optic disc? a. By rotating the diopter to the block (positive) numbers until the optic disc comes into focus b. By following the retinal vessels inward toward the nose until optic disc is seen c. By using the green beam light while looking outward toward the ear until the disc is seen d. By locating the macula and then looking temporally (toward the ear) until the disc is seen

b

During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk for skin cancer? a. Use a tanning booth instead of sunning outside if a tan is desired. b. Wear protective clothing while in the sun. c. Perform self-examination of skin monthly. d. Use sunscreen with a sun protection except on overcast days.

b

During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patients eyes. How does a nurse document this finding? a. An expected racial variation b. Nystagmus c. Exophthalmus d. Myopia

b

During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse? a. Repeat the test again using a 2000 Hz tuning fork. b. Tell the patient that this represents an expected finding. c. Refer the patient for additional testing to detect hearing abnormality. d. Perform a Weber test to confirm the findings of the Rinne test.

b

When palpating the right lobe of the patients thyroid gland using the anterior approach, the nurse feels the tissue between which two structures? a. Sternocleidomastoid and the trapezius muscles b. Trapezius muscle and the trachea c. Cricoid process and the trachea d. Sternocleidomastoid muscle and the trachea

d

During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patients eyes? a. Anterior chamber depth is shallow. b. Red reflex is absent. c. Extraocular muscle movement is asymmetric. d. Retinal arteries are wider than retinal veins.

b

How does the nurse perform a Weber test to assess hearing function? a. Whispers three to four words into the patients ear and asks him to repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process and asks the patient to signal when he can no longer hear the sound

b

How does the nurse test the function of the patients spinal accessory nerve (CN XI)? a. Ask the patient to stick out the tongue and move it side to side. b. Ask the patient to shrug the shoulders against the resistance of the nurses hands. c. Ask the patient to open the mouth and observe the uvula rise when he says ah. d. Ask the patient to move the chin to the chest and then up toward the ceiling.

b

In assessing a patient with head injury, the nurse should be most concerned with which finding? a. Pain on palpation of the scalp b. Unilateral clear, watery nasal discharge c. A scalp laceration at the sight of injury d. Complaints of dizziness

b

The nurse is comparing pitch and duration of the various types of a patients breath sounds and recognizes which one of these as an expected finding? a. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory ratio. b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio. c. Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versus-expiratory ratio. d. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio.

b

The nurse palpates the patients jaw movement, placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What additional request does the nurse ask the patient to do to assess the jaw? a. Clinch the jaws together as tightly as possible. b. Move the lower jaw from side to side. c. Open the mouth as wide as possible, like a yawn. d. Move the lower jaw forward and backward several times.

b

To assess jaw movement of an adult patient, the nurse uses which technique? a. Asking the patient to open the mouth and then passively moving the patients open jaw from side to side b. Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth c. Asking the patient to open the mouth and to resist the nurses attempt to close the mouth d. Using the pads of all fingers to feel along the mandible for tenderness and nodules

b

What technique does a nurse use when palpating the right lobe of a patients thyroid gland using the anterior approach? a. Pushes the cricoid process to the left with the right thumb b. Displaces the trachea to the right with the left thumb c. Manipulates the thyroid between the thumb and index finger d. Moves the sternocleidomastoid muscle to the right with the left thumb

b

When inspecting a patients posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal? a. Both tonsils have a smooth surface. b. Left and right tonsils meet at the midline. c. Left and right tonsils extend beyond the posterior pillars. d. Both tonsils have a glistening appearance.

b

Which finding on assessment of a patients eyes should the nurse document as abnormal? a. An Asian American patient with an upward slant to the palpebral fissure b. A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris c. An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus d. An American Indian patient whose pupillary diameters are 5 mm bilaterally

b

Which patient in the eye clinic should the nurse assess first? a. The patient who reports a gradual clouding of vision b. The patient who complains of sudden loss of vision c. The patient who complains of double vision d. The patient who complains of poor night vision

b

Which question will give the nurse additional information about the nature of a patients dyspnea? a. How often do you see the physician? b. How has this condition affected your day-to-day activities? c. Do you have a cough that occurs with the dyspnea? d. Does your heart rate increase when you are short of breath?

b

During an eye assessment, the nurse asks the patient to keep the head stationary and by moving the eyes only follow the nurses finger as it moves side to side, up and down, and obliquely. This assessment technique collects what data about which cranial nerves? Select all that apply. a. Cranial nerve II (optic) b. Cranial nerve III (oculomotor) c. Cranial nerve IV (trochlear) d. Cranial nerve VI (abducens) e. Cranial nerve V (trigeminal)

b, c, d

On inspection, the nurse finds the patients anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? Select all that apply. a. Inspiratory wheezing found on auscultation b. Hyperresonance heard on percussion c. Decreased breath sounds heard on auscultation d. Deceased diaphragmatic excursion on percussion e. A sharp, abrupt pain reported when the patient breathes deeply f. Decreased to absent vibration on vocal fremitus

b, c, d, f

During an examination of the head and neck of a healthy adult, the nurse expects which findings? Select all that apply. a. Small red lesions with white flakes scattered on the scalp b. The head and facial bones are proportional for the size of the body c. Depressions palpated on the right and left sides over the parietal bones d. Head held flexed 15 degrees to the left e. Face and jaw are symmetric and proportional f. Temporomandibular joint moves smoothly

b, e, f

What findings does the nurse expect when assessing skin, hair, and nails of a healthy male adult? Select all that apply. a. Transverse depression noticed across nails b. Scalp is bald c. Elevated, firm, circumscribed area less than 1 cm wide found on the fingers d. Purpura and ecchymosis are noticed on arms and legs e. Freckles are noted on face, back, arms, and legs f. Skin turgor is elastic

b, e, f

A nurse assesses neck range of movement of several adults. Which patient has an expected range of motion of the neck? a. Patient A is unable to resist the nurses attempt to move the head upright. b. Patient B bends the head to the right and left (ear to shoulder) 15 degrees. c. Patient C flexes chin toward the chest 45 degrees. d. Patient D hyperextends the head 30 degrees from midline.

c

A nurse examines a patient with a pleural effusion and finds decreased fremitus. What additional abnormal finding should the nurse anticipate during further examination? a. An increase in the anteroposterior to lateral ratio b. Hyperresonance over the affected area c. Absent breath sounds in the affected area d. Increased vocal fremitus over the affected area

c

A nurse inspects a patients hands and notices clubbing of the fingers. The nurse correlates this finding with what condition? a. Pulmonary infection b. Trauma to the thorax c. Chronic hypoxemia d. Allergic reaction

c

A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is the appropriate technique to use? a. Systematically percuss the posterior chest wall following the same pattern that is used for auscultation and listen for a change in tone from resonant to dull. b. Place the pads of the fingers on the right and left thoraces and palpate the texture and consistency of the skin feeling for a crackly sensation under the fingers. c. Place the palms of the hands on the right and left thoraces, ask the patient to say 99, and feel for vibrations. d. Place both thumbs on either side of the patients spinal processes, extend fingers laterally, ask the patient to take a deep breath, and feel for vibrations.

c

A nurse notices multiple lesions on a patients left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. What kind of primary lesions are these? a. Macules b. Patches c. Vesicles d. Bullae

c

A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the significance of this finding? a. An expected finding b. Chronic obstructive pulmonary disease c. Bilateral pneumonia d. Bilateral pneumothorax

c

A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how does the nurse expect this patients tympanic membrane to appear? a. Dull b. Shiny c. Red d. Blue to deep red

c

A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action? a. Document this finding as an abnormal finding. b. Assess the patient for accommodation. c. Document this finding as a consensual reaction. d. Assess the patients corneal light reflex.

c

A nurse suspects the patient has an infection of the maxillary sinuses. How can this suspicion be confirmed? a. Using a flashlight to illuminate the floor of the mouth b. Pressing gently with both thumbs into the eyebrow ridges c. Applying firm pressure with the thumbs below the cheekbones d. Standing behind the patient and asking him or her to slowly rotate the head

c

A nurse uses which technique to assess a patients peripheral vision? a. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurses finger as it moves side to side, up and down, and obliquely. b. The nurse covers one of the patients eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement. c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. d. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.

c

A nurses presentation to patients on risk factors for oral cancer includes which fact? a. The peak incidence oral cancer is before 40 years of age. b. Women have a higher risk than men. c. Excessive alcohol consumption is a risk factor. d. Eating a low fiber diet is a risk factor.

c

A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patients ears? a. Redness and edema of the pinna of the right ear b. Report of pain when the nurse manipulates the right ear c. Bulging and red tympanic membrane in the right ear d. Increased cerumen in the right ear canal

c

A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurses examination, what findings will suggest that the cause of this patients dyspnea is due to heart disease rather than respiratory disease? a. Increased anteroposterior diameter b. Clubbing of the fingers c. Bilateral peripheral edema d. Increased tactile fremitus

c

A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time? a. Auscultate the temporal arteries for bruits. b. Palpate the arteries with the patient in supine position. c. Document this as an expected finding. d. Measure the patients blood pressure.

c

A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose? a. Deviated septum b. Pale turbinates c. Perforated nasal septum d. Localized erythema and edema

c

A patient reports the mole on the scalp has started itching and it bleeds when scratching it. What other finding is a danger sign for pigmented skin lesions? a. Symmetry of the lesion b. Rounded border c. Color variation d. Size less than 6 mm wide

c

A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years? a. 10 b. 20 c. 40 d. 60

c

As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings? a. An expected finding b. Koilonychia (spoon nail) c. Clubbing d. Leukonychia

c

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? a. Increased fremitus over the left chest b. Tracheal deviation to the left side c. Hyporesonant percussion tones over the left chest d. Distant to absent breath sounds over the left chest

d

During a Weber test, a patient with right ear hearing loss reports hearing sound longer in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test? a. Air conduction will be twice as long as bone conduction (2:1 ratio). b. Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio). c. Bone conduction will be longer than air conduction. d. Bone conduction will be equal to air conduction.

c

During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patients covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patients eyes? a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered eye

c

During inspection of a patients upper back, the nurse notices three small, elevated superficial lesions filled with purulent fluid. How does the nurse document this finding? a. As three cysts on the upper back b. As several bullae on the back c. As three pustules on the upper back d. As three wheals on the upper back

c

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? a. I felt faint, like I was going to pass out. b. I just could not keep my balance when I sat up. c. It seemed that the room was spinning around. d. I was afraid that I was going to lose consciousness.

c

How does a nurse assess movements of the eyes? a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover test

c

How does the nurse recognize jaundice in a dark-skinned patient? a. Inspect the conjunctiva for ashen-gray color. b. Inspect the nail beds for a deeper brown or purple skin tone. c. Inspect the palms and soles for yellowish-green color. d. Inspect the oral mucous membrane for yellow color.

c

In reviewing the patients record, the nurse notes that the patient has air in the subcutaneous tissue. The nurse validates that this patient has crepitus with which finding? a. Asymmetric expansion of the chest wall on inhalation b. Increased transmission of vocal vibrations on auscultation c. Crackling sensation under the skin of the chest on palpation d. Coarse grating sounds heard over the mediastinum on inspiration

c

On inspection, a nurse finds the patients anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate? a. Increased vocal fremitus on palpation b. Dull tones heard on percussion c. Decreased breath sounds on auscultation d. Complaint of sharp chest pain on inspiration

c

The nurse is taking a health history on a patient who reports frequent headaches with pain in the front of the head, but sometimes felt in the back of the head. Which statement by the patient is most indicative of tension headaches? a. I usually have nausea and vomiting with my headaches. b. My whole head is constantly throbbing. c. It feels like my head is in a vice. d. The pain is on the left side over my eye, forehead, and cheek.

c

What changes in using the ophthalmoscope should the nurse need to make when inspecting the eye of a patient who is nearsighted? a. Holding the ophthalmoscope in the right hand when inspecting the patients right eye b. Using the grid light of the lens aperture to visualize the internal structures of the eye c. Rotating the diopter to the red (minus) numbers d. Asking the patient to look directly into the ophthalmoscope light

c

What findings does a nurse expect when inspecting and palpating a patients nails? a. A nail base angle of not more than 90 degrees b. Whitish to clear nails in darker-skinned patients c. Nail surface is smooth and rounded d. Transverse depression running across the nails

c

What instructions does the nurse give the patient before palpating the right supraclavicular lymph nodes? a. Lean your head backward and toward the right as far as comfortably possible. b. Lie supine and turn your head away from the right side. c. Draw up your shoulders forward, and flex your chin toward the right side. d. Sit up, raise both arms over your head, and flex your chin away from the right side.

c

What instructions does the nurse give the patient before using the Snellen visual acuity chart? a. Remove your eyeglasses before attempting to read the lowest line. b. Stand 10 feet from the chart and read the first line aloud. c. Hold a white card over one eye and read the smallest possible line. d. Squint if necessary to improve the ability to read the largest letters.

c

What technique does a nurse use when palpating the right lobe of a patients thyroid gland using the posterior approach? a. Pushes the cricoid process to the left with the right thumb and feels the right lobe with the left hand b. Uses the left hand to push the sternocleidomastoid muscle to the right and feels the lobe with the right hand c. Pushes the trachea to the right with the left hand and feels the right lobe with the right hand d. Places the fingers on either side of the trachea above the cricoid cartilage and feels the right lobe

c

While inspecting the skin, a nurse notices a lesion on the patients upper right arm. What is the best way to document the size of this lesion? a. Compare its size to the size of a coin. b. Estimate its size to the nearest inch. c. Use a centimeter ruler to measure the lesion. d. Trace the lesion onto a piece of paper.

c

While taking a history, the nurse observes that the patients facial cranial nerves (CN VII) are intact based on which behaviors of the patient? a. The patients eyes move to the left, right, up, down, and obliquely during conversation. b. The patient moistens the lips with the tongue. c. The sides of the mouth are symmetric when the patient smiles. d. The patients eyelids blink periodically.

c

A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurses most appropriate response to this patient? a. This is simple vellus hair and it will decrease in amount over time. b. Some women in your cultural group normally have dark hair on their faces. c. This is unusual; female hair distribution should be limited to arms, legs, and pubis. d. Coarse dark hair could result from hormonal changes such as from menopause.

d

A patient comes to the clinic for evaluation after a sinus infection. To evaluate the therapy, the nurse uses transillumination to assess the sinuses and notes which finding indicating recovery from a frontal sinus infection? a. The soft palate illuminates brightly when the light source is placed against the lateral nose. b. No illumination is noted when the light source is placed firmly against the lateral nose. c. A bright glow illuminates the hard palate when the light source is placed against each temporal bone. d. A reddish light is noted above the eyebrows when the light is placed against each supraorbital rim.

d

A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles and skin that is softened and broken down between the toes? What explanation does the nurse give the patient about the cause of this skin disorder? a. Your itching is caused by a bacterial infection. b. Your itching is caused by an allergic reaction. c. Your itching is caused by a viral infection. d. Your itching is caused by a fungal infection.

d

A patient complains of sore throat, pain with swallowing, fever, and chills. The nurse suspects tonsillitis and plans to palpate the anterior cervical lymph nodes. Where does the nurse place his fingers to palpate these nodes? a. In front of the ears b. Under the mandibles c. Along the angle of the mandibles d. Adjacent to the sternocleidomastoid muscles

d

A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes? a. Dull sounds on percussion b. Soft, muffled rhonchi heard over the trachea c. Bubbling or rasping sounds heard over the trachea d. High-pitched sounds on inspiration and exhalation

d

A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion? a. As an angioma b. As purpura c. As petechiae d. As ecchymosis

d

A toddler patient has a small, slightly raised bright red area on the trunk. The childs mother reports that the lesion has been present since birth and has become a little larger. What type of lesion does the nurse suspect? a. Vascular nevi b. Purpura c. Ecchymosis d. Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age.

d

During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination? a. Increased tactile fremitus b. Inspiratory and expiratory wheezing c. Tracheal deviation d. An increased anteroposterior diameter

d

During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? a. Virus b. Allergy c. Fungus d. Bacteria

d

During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the patients skin, what finding will confirm the rash? a. Elevated, firm, well-defined lesions less than 1 cm in diameter b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter c. Elevated, fluid-filled lesions less than 1 cm in diameter d. Flat, well-defined, small lesions less than 1 cm in diameter

d

During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what does the nurse expect for during the examination of this patients mouth? a. Cracks and erythema in the corners of the mouth b. Slightly rough papillae on the dorsal surface of the tongue c. Smooth or beefy, red-colored, edematous tongue d. Painless, nonhealing mouth ulcers

d

How does a nurse recognize a patients mydriasis? a. The lens of each of the patients eyes is opaque. b. There is involuntary rhythmical, horizontal movement of the patients eyes. c. There is a white opaque ring encircling the patients limbus. d. The patients pupils are 7 mm and do not constrict.

d

How does a nurse recognize normal accommodation? a. The patient has peripheral vision of 90 degrees left and right. b. The patients eyes move up and down, side to side, and obliquely. c. The right pupil constricts when a light is shown in the left pupil. d. The patients pupils dilate when looking toward a distant object.

d

How does the nurse perform a Rinne test of hearing function? a. Whispers several words to the patient and requests that the patient repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it

d

On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding? a. As an indication of a type of anemia b. As a hordeolum or sty c. As jaundice d. As an expected racial variation

d

The nurse is taking a health history on a patient who reports frequent stabbing headaches occurring once a day lasting about an hour. Which statement by the patient is most indicative of cluster headaches? a. I usually have nausea and vomiting with my headaches. b. My whole head is constantly throbbing. c. It feels like my head is in a vice. d. The pain is on the left side over my eye, forehead, and cheek.

d

Wearing gloves, the nurse grasps the patients tongue with a gauze pad and palpates a small, firm nodule on the left side of the tongue. Based upon this finding, what is the nurses appropriate response? a. Document that the patients tongue is normal on palpation. b. Inspect the left submandibular salivary glands for redness. c. Ask the patient to move the tongue in all directions. d. Palpate cervical and submental lymph nodes for enlargement.

d

When performing a skin assessment of an adult patient, the nurse expects what finding? a. Reddened area does not blanch when gentle pressure is applied b. Indentation of the finger remains in the skin after palpation c. Flaking or scaling of the skin d. Return of skin to its original position when pinched up slightly

d

Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult? a. In the lower lobes b. Over the trachea c. In the apices of the lungs d. Near the sternal border

d

Which finding warrants a referral for additional evaluation? a. Earlobes hanging freely from the base of the pinna b. Ears having painless nodules less than 1 cm in diameter at the helix c. Ears measuring 8 cm in length d. Pinna is 20 degrees lower than the outer canthus of the eye

d

While taking a history, the nurse notices that the patients family member repeats most of the questions to the patient in a loud voice. Based on this information, what finding does the nurse anticipate when assessing this patients hearing using an audioscope? a. 5 dB hearing loss at all frequencies b. 10 dB hearing loss at all frequencies c. 20 dB hearing loss at all frequencies d. 40 dB hearing loss at all frequencies

d