HEALTH ASSESSMENT SITUATIONAL REVIEWER

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

"It is difficult to prevent hearing loss or worsening of hearing"

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

2 years

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing arching pain in his right eye. The nurse should assess the client for

A foreign body in the eye

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

An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for

Allergies

The nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to

An upper respiratory infection

The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the

Area underneath the tongue

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should

Check the client's blood pressure

The transmission of sound waves through the external ear and the middle ear is known as

Conductive hearing

The nurse has performed the Rinne test on an older adult client. After the trst, 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

Conductive hearing loss

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too lon the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to

Corneal damage

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's

Corneal reflexes

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 determines that the client has understood the instructions when the client says that presbyopia is

Decreased accommodation

The nurse is planning to inspect an adult client's mouth, using a tongue depressor. The nurse should plan to

Depress the tongue blade slightly off center

The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan?

Diets low in fruits and vegetables are a possible risk for oral cancer

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should

Document the findings in the client's records

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

Esotropia

An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spots in her left eye. The nurse should refer the client for evaluation of possible

Glaucoma

An adult client visits 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 vision are often associated with

Head trauma

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

Increased intracranial pressure

While assessing the ears of an 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

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 client's eye for

Lacrimal obstruction

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the

Maxillary sinuses

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should

Observe the client's response to the explanations

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

Position the client 609.6 cm (20ft) away from the chart

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to

Position the handle of the otoscope to one side

A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should

Refer the client for further evaluation

An adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. The nurse should

Refer the client for further evaluation

While assessing the ears of an adult client, the nurse observes bloody drainage in the client's ear. The nurse should

Refer the client to a physician

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

Refer the client to an ophthalmologist

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should

Refer the client to an optometrist

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 on the center of the client's head or forehead

An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been

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 aging

An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are

Touching each other

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

UV light exposure

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

Vitamin A deficiency

The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to

firmly pull the auricle out, up and back