health assessment

the nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every year 2 year 3 year 4 year

2 years

While asses an adult clients jaw the nurse hears a clicking popping sound and the client expresses pain in the joint. The nurse should further asses the client for arthritis TMJ dysfunction bruxism previous fracture

TMJ dysfunction

the middle layer of the eye is known as the choroid laywe sclera layer retinal layer optic layer

choroid layer

The cone of lights is located in the inner ear middle ear external ear semicircular canal

external ear

two body systems that may be logically integrated and assessed at the same time are the eyes and ears eye exam and cranial nerves 2,3,4,5 ear exam and cranial nerves 2,3,4,5 ear and nose exams

eye exam and cranial nerves 2,3,4,5

which cranial nerve is the nurse testing when the client is asked to identify a scented object oculomotor facial optic olfactory

oculomotor

One of the functions of a bone is to store fat produce secretions produce blood cells store protein

produce blood cells

the bony orbit and fat cushion of the eye serves as a carunlce channel protector filter

protector

straight movements of the eye are controlled by the lacrimal muslces oblique muscles corneal muscles rectus muscles

rectus muscles

a client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should examine the area of head trauma refer the client to an ophthalmologist assess the client for double vision ask the client if he sees "halos"

refer the client to an opthalmologist

A client has tested 20/40 on the distant visual acuity test using a snellen chart. document the results in the clients record ask the client to read a handheld vision chart ask the client to return in 2 weeks refer the client to an optometrist

refer the client to an optometrist

The ossicles contained in the middle ear include the malleus, the incus, and the pars tensa pars flaccida umbo stapes

stapes

skeletal muscles are attached to bones by tendons cartilage fibrous connective tissue ligaments

tendons

the meibomian glands secrete an oily substance to lubricate the eye sweat hormones clear liquid tears

an oily substance to lubricate the eyes

while assessing the eyes of the adult client, the nurse uses a wisp of cotton to stimulate client's eyelid reflexes refractory mechanism lacrimal reflexes corneal reflexes

corneal reflexes

the cerebrum is divided into right and left hemispheres which are joined together by the corpus callosum diencephalon medulla oblongata pons

corpus callosum

The nurse is assessing the neurologic system of a client who has spastic muscle tone, the nurse should explain the client that spastic muscle tone is associated with impairment to the extrapyramidal tract spinothalamic tract posterior columns coricospinal tract

corticospinal tract

The nurse has tested an adult clients visual fields and determined that the temporal field is 90 degrees in both eyes. the nurse should refer the client for further evaluation examine the client for other signs of glaucoma ask the client if there is a genetic history of blindness document the findings in the clients records

document the findings in the clients records

bones contain yellow marrow that is composed mainly of fat protein cartilage carbs

fat

joints may be classified as cartilaginous synovial, or articulate flexible immobile fibrous

fibrous

the nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to ask the client to tilt the head slightly forward release the auricle during the examination use a speculum that measures 10mm in diameter firmly pull the auricle out, up, and back

firmly pull the auricle out, up, and back

in the hearing pathway, hair cells of the spiral organ of Corti are stimulated by movement of fluid sound air bone

fluid

the cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the vagus hypoglossal trigeminal glossopharyngeal

glassopharyngeal

an adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to gouty arthritis osteomalacia bone fractures osteomuelitis

gouty arthritis

the portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex us the gray matter cerebellum diencephalon brainstem

gray matter

an adult client visit the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in the vision are often associated with diabetes the aging process hypertension head trauma

head trauma

An adult client tells the nurse that his 80-year-old father is almost completely deaf. After an explanation to the client about risk factors for hearing loss, the nurse, determines that the client needs further instruction when the client says there is a genetic predisposition certain cultural groups have a higher rate of hearing loss it is difficult to prevent hearing loss or worsening of hearing chronic otitis media has been associated with hearing loss

it is difficult to prevent hearing loss or worsening of hearing

bones in synovial joints are joined together by cartilage ligaments tendons periosteal tissue

ligaments

the optic nerves from each eyeball cross at optic chiasma vitreous humor optic disc visual cortex

optic chiasma

the nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the clients sensation in the extremities deep tendon reflex ability to speak recent memory

sensation in the extremities

sensations of temperature, pain, and crude and light touch are carried by way of the extrapyramidial tract corticospinal tract spinothalamic tract posterior tract

spinothalamic tract

when the nurse moves a clients leg upward, the nurse is performing supination external rotation eversion internal rotation

supination

when the nurse moves the clients arm away from the midline of the body, the nurse is performing adduction external rotation retraction abduction

abduction

before beginning a physical assessment it is important for the nurse to explain to the client in detail how each body system will be assessed explain to the client the purpose of every physical assessment technique acquired your clients verbal permission to perform the physical examination acquire your clients written permission to perform the physical examination

acquired your clients verbal permission to perform the physical examination

an adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for foreign body recent trauma blind spots allergies

allergies

While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for arthritis ganglion cust carpal tunnel syndrome nerve damage

arthiritis

a client visits the clinic and tells the nurse that she has join pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of arthritis osteoporosis carpal tunnel syndrome neurologic disorders

arthritis

The nurse is assessing the neurologic system of an adult client. To test the clients motor function of the facial nerve, the nurse should ask the client to purse the lips ask the client to open the mouth and say ah note the presence of a gag reflex observe the client swallow a sip of water

ask the client to purse the lips

when integrating the total physical examination the nurse should -perform the mental status exam after examining all other body systems -assess cranial nerve 1 with the other 11 cranial nerves at the same time -assess peripheral vascular status when examining the lower extremities -integrate the rectal examination with the abdominal examination

assess peripheral vasuclar status when examining the lower extremities

while assessing muscle strength in an older adult client, the nurse determines that the clients knee joint has a rating of 3 and exhibits active motion against gravity. The nurse should document the clients muscle strength as being normal slight weakness average weakness poor range of motion

average weakness

the conjunctiva of the eye is divided into the palpebral portion and the canthus portion intraocular portion nasolacrimal portion bulbar portion

bulbar portions

While assessing an older adult client, the client complains of chronic pain and severe limitation of all shoulder movements. The nurse should refer the client to a physician for possible rotator cuff tear RA calcified tendinitis chronic bursitis

calcified tendinitis

while assessing the neurological system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of depression anxiety ADD cerebral cortex disorder

cerebral cortex disorder

an adult client tells the nurse that he has been experiencing gradual vision loss. the nurse should ask about the clients diet determine whether there is a history of glaucoma check the clients blood pressure ask the client if he has any known allergies

check the clients blood pressure

the chambers of the eye contain aqueous humor which helps to maintain intraocular pressure and transmit light rays maintain the retinal vessels change refractory of the lens cleanse the cornea and the lens

cleanse the cornea and the lens

the nurse is preparing to percuss a clients reflex in his arms. To use the reinforcement technique, the nurse should ask the client to clench his jaw stretch the opposite arm hold his neck toward the floor straighten his legs forward

clench his jaw

The transmission of sound waves through the external ear and the middle ear is known as perceptive hearing conductive hearing external hearing connective hearing

conductive hearing

The nurse has performed the rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing normal hearing sensorineural hearing conductive hearing loss external hearing connective hearing

conductive hearing loss

an adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contacts lenses can lead to retinal damage cataracts myopia corneal damage

corneal damage

the nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determined that the client has understood the instructions when the client says that presbyopia is usually due to congenital cataracts decreased accommodation muscle weakness constant misalignment of the eyes

decreased accomodation

While assessing the eye of an adult client, the nurse observes an inward turning of the clients left eye. The nurse should document the clients esotropia strabismus phoria exotropia

esotropia

a client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is "locking up" the nurse should perform the mcmurray test by asking the client to move from a standing to a squatting position raise his leg while in supne position bend forward while trying to touch the toes flex the knee and hip while in a supine position

flex the knee and hip while in a supine position

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in the right eye. the nurse should assess the client for recent exposure to irritants increased intracranial pressure excessive tearing foreign body in the eye

foreign body in the eyes

an adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible glaucoma increased intracranial pressure bacterial infection migraine headaches

glaucoma

The best approach to use when performing a total physical examination on a client is toe-to-toe integrated assessment of body systems head-to-toe integrated assessment of the body systems total body system approach examining each body system individually any approach that is convenient for you and the client

head-to-toe integrated assessment of the body systems

While examining the spine of an adult client, the nurse notes that the client has a flattened lumbar curvature. The nurse should refer the client to a physician for possible herniated disc scoliosis kyphosis cervical disc degeneration

herniated disc

an older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of herniated intervertebral disc RA osteoporosis metastases

herniated intervertebral disc

While reviewing a clients chart before seeing the client for the first time, the nurse notes that the client has a diagnosis of dupuytren contracture. The nurse anticipates that the client will exhibit. inability to turn the wrist ulnar deviation of the hands flexion of the distal interphalangeal joints inability to extend the ring and little finger

inability to extend the ring and little finger

While assessing the ears of adult client, the nurse observes that the tympanic membrane is completely immobile. The nurse should further assess the client for signs and symptoms of infection skull injury vestibular disorders healed perforations

infection

examination of the skin should be -integrated throughout the head-and-toe examination -completed at the beginning of the physical assessment before proceeding to other parts of the exam -performed at the very end of the physical assessment -integrated and completed only with the muscoloskeletal examination

integrated throughout the head to toe examination

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the clients eye for viral infection double vision allergic reaction lacrimal obstruction

lacrimal obstruction

a client visits the clinic and tells the nurse that he has had lower back pain for the past several days. To perform lasegue test, the nurse should ask the client to bend backward toward the nurse lean forward and touch his toes twist the shoulders in both directions lie flat and raise his legs to the point of pain

lie flat and raise his leg to the point of pain

the tarsal plates of the upper eyelid contain meibomian glands sebacous glands tear ducts ocular muscles

meibomian glands

The nurse is planning a presentation on osteoporosis to a group of high school students. Which of the following should the nurse plan to include in the presentation bone density rises to a peak at age 50 for both sexes bone density in the asian population is higher than in the white population moderate strenuous exercise tends to increase bone density approximately 5 million fractures in the US are due to osteoporosis

moderate strenuous exercise tends to increase bone density

The nurse is planning to perform an ear examination of an adult client. After explaining the procedures to the client, the nurse should ask the client to remain standing show the client the otoscope ask the client to remove his contact lenses observe the clients response to the explanations

observe the clients response to the explanations

an adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible glaucoma increased intracranial pressure hypertension ophthalmic migraine

opthamalic migrane

while assessing the musculoskeletal system of an adult client, the nurse observes hard painless nodules over the distal interphalangeal joints. the nurse should document the presence of osteoarthritis bursitis tendonitis RA

osteoarthritis

a clients with insulin-dependent diabetes visits the clinic and complains of painful hip joints. The nurse should assess he client carefully for signs and symptoms of arthritis gait difficulties osteomyelitis scoliosis

osteomyelitis

A female client visits the clinic and tells the nurse that she began menarche at the age of 16. the nurse should instruct the client that she is at a higher risk for osteoporosis osteomyelitis rheumatoid arthritis lordosis

osteoporosis

Transmission of sound waves in the inner ear is known as conductive hearing tympanic hearing neuromotor hearing perceptive hearing

perceptive hearing

the external coverage of the bone that contains osteoblasts and blood vessels is termed the cartilage synovial membrane connective tissue periosteum

periosteum

reduced availability to sense vibrations of a tuning fork may be present with peripheral neuropathy nystagmus graphesthesia stereognosis

peripheral neuropathy

the nurse is preparing to examine an adult clients eyes, using the snellen chart. The nurse should position the client 20 feet away from the chart ask the client to remove his glasses ask the client to read each line with both eyes open instruct the client to begin reading from the bottom of the chart

position the client 20 ft away from the chart

While assessing the ears of adult client, the nurse observes bloody drainage in the clients ear. the nurse should document the finding in the clients chart determine whether a foreign body is present assess the client for further signs of otitis media refer the client to a physician

refer the client to a physician

The cerebrospinal fluid cushions the central nervous system provides nourishment to the CNS and transmits impulses coats the brain regulates heart rate removes wastes

removes wastes

The nurse is examining an adult clients eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test assesses the muscle strength of the eye assesses the functioning of the cranial nerves innervating the eye muscles requires the covering of each eye separately requires the client to focus on an object

requires the covering of each eye separately

photoreceptors of the eye are located in the eye's ciliary body lens retina pupil

retina

while assessing the ROM in an adult clients shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible rotator cuff tear nerve damage cervial disc degeneration tendonitis

rotator cuff tear

The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing lordosis arthritis kyphosis scoliosis

scoliosis

the subacromial bursae are contained in the temporomandubular joint shuolder joint elbow joint wrist joint

shoulder joint

the hypothalamus is responsible for regulating sleep cycles nerve impulses memory eye reflexes

sleep cycles

The nurse is planning a presentation to a group of adults on the topic of strokes. Which of the following should the nurse plan to include in the teaching plan -strokes are the number one cause of death in the US -smoking and high cholesterol levels are risk factors for stroke -clients who smoke while taking oral contraceptives are not at higher risk -postmenopausal women taking estrogen are at greater risk for stroke

smoking and high cholesterol levels are risk factors for stroke

the nurse is preparing to perform the romberg test on an adult male client. The nurse should instruct the client to squat down as far as he is able to do so keep his eyes open while he bends at the knees stand erect with arms at the sides and feet together touch the tip of his nose with his fingers

stand erect with arms at the sides and feet together

the nurse is planning to conduct the weber test on an adult male client. To perform this test, the nurse should plan to strike a tuning fork and place it at the base of the clients mastoid process whisper a word with two distinct syllables to the client ask the client to close his eyes while standing with feet together strike a tuning fork and place it on the center of the clients head or forehead

strike a tuning fork and place it on the center of the clients head or forehead

the nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible vagus nerve damage stroke spinal cord compression parkison disease

stroke

An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been dizzy hypotensive taking antibiotics experiencing ear drainage

taking antibiotics

a 45 year old client tells the nurse that he occasionally sees spots in front of his eyes. the nurse should tell the client that these often occur with again refer the client to an ophthalmologist re-examine the client in 2 weeks assess the client for signs of diabetes

tell the client that these often occur with aging

The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the clients arms away from the body toes up or down hand forward and then backward leg away from the body

toes up or down

an adult client tells the nurse that his father had cataracts. He asks the nurse about the risk factors for cataracts. The nurse should instruct the client that a potential risk factor is lack of vit C ultraviolet light exposure obesity use of antibiotics

ultraviolet light exposure

Sensory receptors in the ear that help to maintain both static and dynamic equillibrium are located in the semiciruclar canals and the vestibule typanic membrane cone of light eustachian tube

vestibule

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with retinal deterioration head trauma migraine headaches vitamin a deficiency

vitamin A deficiency

the nurse is caring for an adult client who is in a cast because of a fractured arm. To promote healing of the bone and tissue, the nurse should instruct the client to eat a diet that is high in while grains Vit B vit E vit C

vitamin C

a client tells the nurse that his grandmother had a diagnosis of osteomalacia. The nurse should instruct the client that to decrease the risk factors for osteomalacia, the clients should have adequate amounts of vit E riboflavin b-carotene vit D

vitamin D

The nurse is assessing the neurological system of an adult client. to test the clients recent memory, the nurse should ask the client what did you have for breakfast how old were you when you began working who is the 44th president can you recall the name of your first grade teacher

what did you have for breakfast

the nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. The nurse determines that the client needs further instruction when the client says you will be asking me to change positions often youll be comparing bilateral joints youll be assessing the size and strength of my joints youll continue with range of motion even if i have discomfort

youll continue with range of motion even if i have discomfort

the functional reflex that allows the eyes to focus on near objects is termed pupillary reflex accomodation refraction indirect reflex

accomodation

after examining the client's tympanic membranes, the nurse documents "right tympanic membrane, red and bulging with no light reflex" the nurse recognizes that these are signs of acute otitis media serous otitis media skull trauma trauma from infection

acute otitis media

articulation between the head of the femur and the acetabulum is in the knee joint tibial joint ankle joint hip joint

hip joint

while assessing the pupils of a hospitalized adult client, the nurse observes that the clients pupils are dilated to 6cm. The nurse suspects that the clients is exhibiting signs of oculomotor nerve paralysis damage to the pons alcohol abuse cocaine abuse

oculomotor nerve paralysis

the diencephalon of the brain consists of the pons and brainstem medulla oblongata and cerebrum cerebrum and midbrain thalamus and hypothalamus

thalamus and hypothalamus