RN 102 #2 Exam Sensory, Cardio, Musculoskeletal & Neurological + Cranial Nerves

Which of the following documentation provides the most accurate information to include in the medical records?

Radial pulses +1 bilateral with rate 110 bpm

Which of the following documentation provides the most accurate information to include in the medical record?

Reports the onset of right elbow pain 3 days ago with difficulty of ROM and reports radiation of pain down the arm and middle finger. Client state "It was very uncomfortable to rest my elbow on my desk while using my computer"

Which of the following documentation provides the most accurate information to include in the medical record?

Reports the onset of right elbow pain 3 days ago with difficulty of ROM and reports radiation of pain down the arm and the middle finger. Client states "It was very uncomfortable to rest my elbow on my desk while using my computer"

A nurse is preparing for a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?

Risk factors for sensory deprivation include experiencing total vision or hearing loss

Which of the following is an extra or unexpected heart sounds? (SATA)

S3 S4 Murmur

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?

SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin

A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated.

See Graphic = D

The most common type of hearing loss; occurs from problems either in the inner ear or on the vastibulocochlear (auditory) nerve (cranial nerve VIII)

Sensorineural hearing loss (SNHL)

A nurse is caring for a client who is post-operative. The IV pump and telemetry monitor are alarming. The client's roommate is watching television at a loud volume. The client is experiencing pain at the incision site and discomfort from an indwelling urinary catheter. Which of the following sensory alterations is the client at risk of experiencing?

Sensory Overload

A deficit in the expected function of one or more of their five senses

Sensory deficit

Which of the following is a ball and socket joint?

Shoulder

CN 11 - SPINAL ACCESSORY

Shoulder & Head Rotation Assessment: shoulder movement, shoulder shugs, apply resistance to shoulder to test strength, head rotation.

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease?

Sibling who has hypertension

CN 1 - OLFACTORY

Smell Assessment: Smell Test - Coffee, Cloves, Peppermint

A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make?

This test is performed using lenses of various prescription strengths

The experience of hearing sound when no external sound is present; generally caused by age-related hearing loss, an ear injury, cerumen (earwax) blockage, or a problem with the circulatory system.

Tinnitus

CN 12 - HYPOGLOSSAL

Tongue Movement Assessment stick tongue or move side to side.

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss?

Trauma to outer eat, inflammation, cerumen buildup, and otitis media

In what order does blood flow though the heart valves? (Place steps in correct order.)

Tricuspid Valve Pulmonic Valve Mitral Valve Aortic Valve

CN 6 - ABDUCENS

Turns eye laterally, proprioception, sensory awareness of part of the body. Assessment: 6 Directional Gaze Exam & Penlight = PERLA **Assessment of CN 3, CN 4, & CN 6 performed together.**

Which of the following are signs of peripheral arterial disease (PAD)? (SATA)

Ulcer on the toes Leg Pain that occurs with activity Decreased or absent pulse

CN 2 - OPTIC

Vision Assessment: Snellen Chart

Which of the following should the nurse include when documenting objective findings?

Vital signs Inspection results

A nurse is preparing to collect data about cranial nerve function for a client. Which of the following actions should the nurse take to collect data about cranial never VIII?

Whisper something in one ear while occluding the other ear

A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. How do you respond?

You will have a small probe placed in your ear canal during the test

A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following actions should the nurse take?

apply compression to the injured area of the extremity

a nurse is preparing to perform palpation on a client's knees. In which order should the nurse perform the following steps?

assist client to a sitting position with legs dangling at edge of examination table; palpate quadriceps muscle above knee; palpate hollows on either side of patella with thumbs; follow lower edge of the patella and locate tibiofemoral joint; palpate tibiofemoral joint where femur and tibia meet

a nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the nurse include?

do not text and drive; maintain spinal alignment when working at a desk; remove loose rugs from the home; wear a helmet when riding a bicycle

the nurse is assessing the spinal curvature of a client who has a diagnosis of kyphosis. Which of the following images should the nurse identify as kyphosis?

exaggerated posterior curvature of the thoracic spine

a nurse is preparing to perform palpation of client's shoulder. In what order should the nurse perform the following steps?

face client and palpate along clavicle; face client and palpate the acromioclavicular joint; from the back palpate scapula; from the back palpate greater tubercle of the humerus

a nurse is performing range-of-motion exercises on a client's hips. The nurse is assessing which of the following motions by instructing the client to bend the knee and bring it up toward the chest?

flexion of the hip

a nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse?

for some reason I have been experiencing falls

a nurse is assessing a client's spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend backward as far as they can go?

hyperextension

a nurse is performing a musculoskeletal and neurological assessment. Which of the following actions should the nurse take?

inspect for symmetry on both sides of the body

a nurse is recommending sources of food with high calcium content to a client. Which of the following foods should the nurse recommend?

milk, mustard greens, and legumes

a nurse is assessing a client's wrist and hands. Which of the following findings indicates the client might have arthritis?

nodules on the joints; fingers deviate toward the ulnar

a nurse is performing range-of-motion exercises on a client's feet. the nurse should provide which of the following instructions to the client to assess plantar flexion of the feet

point your toes toward the floor

A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as a age related change?

presbyopia

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age?

salty, sour, bitter

a nurse is assessing the range of motion of a client's hands. The nurse should provide which of the following instructions to assess abduction and adduction of the client's fingers?

spread the fingers apart and then move them back together

a nurse is assessing flexion of a client's elbows. The nurse should provide which of the following instructions to the client?

start with your arms straight out in front of you and then bend your elbows up and bring your fingers toward your shoulders

a nurse is assessing an older adult client while they walk. Which of the following findings should the nurse report to the provider?

the client walks with a shuffling gait

a nurse is assessing a client's head and neck. Which of the following findings should the nurse report to the provider?

there is locking of the jaw joint

a nurse is assessing the range of motion of a client's head and neck. The nurse should provide which of the following instructions to assess hyperextension?

tilt the head back and look up at the ceiling

A nurse is teaching about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (SATA)

"I am going to start walking several times a week. "I plan to join a support group to help me stop smoking. "I will be sure to have my blood pressure checked at least every year."

Which of the following client responses require the nurse to ask additional open-ended questions (SATA)

"I feel so tired even just to put out the trash" "I used to be able to walk everyday, but lately it's been too hard" "Now that you mention it, I did have some chest pain yesterday when I was cleaning out the garage. I had to sit down for a while and rest."

Which of the following client reports indicates a medical emergency?

"I have a tight feeling in my chest"

Which of the following client responses requires you to ask additional open-end questions?

"It's my left knee and I feel like it's been forever that it's been hurting."

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?

"The penlight will allow me to look at the pulses in your neck."

A client is discussing an audiometer test with a client. Which of the following statements should the nurse make?

"You will wear headphones during the test."

What is the correlating scale rating for mild pitting edema that is barely noticeable?

+1

Which of the following ratings should you assign to a bound carotid pulse?

+4

Which of the following documentation provides the most accurate information to include in the medical records?

+4 pitting edema in the left lower leg

a nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of the following intake amounts should the nurse recommend?

1,000 to 1,200 mg daily

Place the lower extremities in the order they should be assessed

1. Hips 2. Knees 3. Ankles 4. Feet

Place the steps of head and neck assessment in the correct order

1. Note the size and contour of every joint. Inspect the skin and tissues over the joints for color, swelling, and any masses or deformity. 2. Inspect and palpate the spinous processes and the sternomastoid, trapezius, and paravertebral muscles. 3. Palpate the temporomandibular joint just anterior to the ear. 4. Ask the client to complete active ROM maneuvers while demonstrating the movements yourself as appropriate. You may stabilize the body are proximal to the area being moved 5. Test the strength of the primary muscle groups for each joint. Repeat the same motions for active ROM, have the client flex and hold it while you provide resistance.

a nurse is providing teaching about adequate daily intake of vitamin D to a client. Which of the following intake amounts should the nurse recommend?

800 IU daily

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include?

A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider?

A forceful chest movement at the midclavicular line in the fourth intercostal space

A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse take?

A tuning fork is placed against the client's mastoid bone during the Rinne test

A nurse is reinforcing teaching about safe ambulation to a client who has become visually impaired. Which of the following items should the nurse include in the teaching?

A walking cane and a walker

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?

Alzheimer's disease

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?

An adolescent who has an S3 heart sound

A disorder that affects a client's ability to articulate and understand speech and written language

Aphasia

Which of the following are nurse interventions for chest pain?

Apply oxygen Provide continuous ECG monitoring Obtain IV access

A nurse is collecting data to determine whether a client has a hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss?

Ask for questions to be repeated, withdraws from social activities, and describes sounds as being muffled.

A nurse is caring for a client who reports a recent change in smell and taste. Which of the following actions should the nurse take?

Ask the client about any recent illnesses or injuries.

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (SATA)

Auscultate the apical pulse Ask the client if they experience shortness of breath Check the color of the client's skin Inspect the extremities for the presence of edema.

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?

Availability of aids to enhance vision

Which of the following are the risk factors for heart disease?

BMI greater than 30 Smoking tobacco Family history of hypertension Type 2 diabetes

A test that determines how effectively vibrations are transmitted through the ossicles.

Bone oscillator test

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?

Capillary refill of 3 seconds

Clouding of the lens of the eye that causes the client's vision to be blurry, hazy, or less colorful.

Cataracts

A nurse is preparing to check the function of a client's cranial nerves. Which of the following actions should the nurse take to collect data about cranial nerve II?

Check the clients visual acuity using a Snellen chart

CN 5 - TRIGEMINAL

Chewing, Face, Mouth, Touch, and Pain Assessment: Sensation of skin of the face,= (eyebrow, cheek, and chin? by using a wisp of cotton. Chewing, bitting, lateral jaw movements. (move jaw side to side)

CN 7 - FACIAL

Controls most facial expressions, secretion of ears and saliva. Assessment: movement of forehead and mouth, raise eyebrows, show teeth, smile, frown, puff out cheeks.

A syndrome that has a rapid onset and causes a disturbance in mental ability resulting in confused thinking and reduced awareness of the environment.

Delirium

Occurs over time from elevated blood glucose and triglyceride levels; nerve damage and loss of sensation in the lower extremities

Diabetic neuropathy

The leading cause of blindness in adults

Diabetic retinopathy

A nurse is collecting data from a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of demention?

Difficult problem-solving

A nurse is collecting data from a client who has delirium. Which of the following manifestations should the nurse expect?

Difficulty maintaining attention, agitation, hallucinations, and rambling speech

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress?

Discuss the benefits of meditation with the client.

A condition in which foul, salty, or metallic taste occurs in the mouth.

Dysgeusia

Which of the following foods promote bone health?

Egg yolks, Salmon, Yogurt, Broccoli

A nurse is auscultating a client's heart sounds. Place the nurse actions for auscultation of the heart in the correct order.

Elevate the head of the bed 30° and instruct the client to breath normally is the first step. Visualize the anatomy of the heart is the second step. Place the stethoscope to the right sternal border at the second intercostal space is the third step. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. Auscultate the apical pulse for 1 min is the fifth step.

A nurse can enhance communication with a client with hearing loss by

Ensure the client is wearing hearing aids, use a sign language interpreter, communicate with pen and paper, and face the client when speaking

A nurse is caring for a client who has a visual impairment. Which of the following interventions is the nurse's priority?

Ensure the client's safety

CN 3 - OCULOMOTOR

Eyelid & eyeball movement Assessment: 6 Directional Gaze Exam & Penlight = PERLA **Assessment of CN 3, CN 4, & CN 6 performed together.**

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (SATA)

Full, bounding pulse noted bilaterally in the carotid arteries upon palpation. Distention of the jugular vein on one side of the neck. The left carotid artery pulse is weak.

CN 9 - GLOSSOPHARYNGEAL

Gag reflex & swallowing Assessment: ask to say "ahh" use tongue depressor, ask to swallowing, speaking without hoarseness. **Assessment for CN 9 & CN 10 performed together**

CN 10 - VAGUS

Gag reflex & swallowing Assessment: ask to say "ahh" use tongue depressor, ask to swallowing, speaking without hoarseness. **Assessment for CN 9 & CN 10 performed together**

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments?

Glaucoma

An increase in intraocular pressure due to the buildup of fluid, or aqueous humor, that causes compression of the optic nerve.

Glaucoma

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?

Have the client lay supine with the head of their bed at a 45° angle.

A nurse is reinforcing teaching with a group of older adult clients about sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?

Hearing loss

CN 8 - VESTIBULOCOCHLEAR

Hearing, equilibrium sensation. Assessment: hearing, balance, whisper test.

Which of the following conditions is associated with jugular venous distention?

Heart failure

CN 4 - TROCHLEAR

Innervates superior oblique eye muscle, turns eye downward and laterally Assessment: 6 Directional Gaze Exam & Penlight = PERLA **Assessment of CN 3, CN 4, & CN 6 performed together.**

A nurse is reinforcing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include?

Inspect the feet every day, wear closed-toe shoes, and manage glucose levels

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (SATA)

Instruct the client to sit with their legs uncrossed. Encourage the client to avoid tobacco products. Instruct the client to cleanse the area with mild soap. Instruct the client to wear shoes when ambulating.

A nurse is caring for a client who states, "my doctor said I should have an EMG. What is that?"

It is a test that determines if there is nerve damage affecting a muscle

A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client?

Keep the client's environment free from clutter

Which of the following is a finding of scoliosis?

Lateral curvature of the spine

Which of the following maneuvers should you assess during ROM of the spine?

Lateral flexion, Hyperextension, Rotation

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include?

Limit sodium intake to less than 3,000 mg/day

Which of the following actions should the client take when applying cold therapy after a sprain?

Limit the use of the cold pack to 20 minutes at a time

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic?

Loop diuretics, NSAIDs, and aminoglycoside antibiotics

Which of the following findings from musculoskeletal assessment should be reported to the provider?

Misalignment of bones of the elbow

Which of the following conditions involve the bones of the joint?

Osteoarthritis

Inflammation in or the accumulation of fluid in the middle ear and can result in conductive hearing loss.

Otitis media

Abnormal growth of bone in the middle ear that can cause conductive hearing loss.

Otosclerosis

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease?

Palpable dorsalis pedal pulse

A nurse is assessing a client who reports pins and needles sensations to their right hand. Which of the following terms should the nurse use to describe the sensation?

Paresthesia

A disorder where a nonexistent smell is perceived

Phantosmia

Loss of hearing that occurs due to aging

Presbycusis