Health Assessment Test 3

A 60 year old client expresses concerns about his sexual drive. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life can be attributed to: A) Decreased sperm production. B) Side effects of medications. C) Increased sperm production. D) Decreased pleasure from sexual intercourse.

B) Side effects of medications.

A client states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the client is experiencing: A) dysuria B) stress incontinence C) hematuria D) urge incontinence

B) Stress incontinence

The nurse is performing an oral assessment and asks the client to stick out his tongue and say "Ahh". She notes that his uvula deviates to one side. She suspects there may be damage to which cranial nerve? A) Cranial Nerve IX B) Cranial Nerve XII C) Cranial Nerve X D) Cranial Nerve VII

C) Cranial Nerve X

A client was admitted to the ED with slurred speech. The nurse notes that this could be due to dysfunction of what cranial nerve(s)? A) Cranial Nerve I B) Cranial Nerve V C) Cranial Nerves IX and X D) Cranial Nerve III

C) Cranial Nerves IX and X

A 92-year-old client has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? A) Epistaxis B) Rhinorrhea C) Dysphagia D) Xerostomia

C) Dysphagia

The nurse is inspecting a female client's perianal area. Which of the following assessment findings, if noted, would be considered abnormal? A) Smooth and even colored sacrococcygeal area B) Dark pink colored labia minora C) Excoriation, inflammation or swelling D) Moist, hairless anus

C) Excoriation, inflammation or swelling

The two sinuses that can be directly palpated are? A. Frontal and Sphenoid B. Maxillary and Ethmoid C. Frontal and Maxillary D. Ethmoid and Sphenoid

C) Frontal and Maxillary

A nurse is assessing a client recently diagnosed with parkinson's disease. What abnormal body movements are typically associated with this disease? A) Myoclonus B) Fasciculations C) Resting tremors D) Tics

C) Resting tremors

Acoustic Nerve Function

Sensory Hearing, balance Weber and Rinne tests Otoscope

During the history the client tells the nurse that "it feels like the room is spinning around me." The nurse would document this as: A) vertigo. B) syncope. C) dizziness. D) seizure activity.

A) vertigo

Vagus Nerve Function

Sensory Sensations of posterior one third of tongue, throat Motor Gag reflex (stimulate back of pharynx with a tongue blade) Swallowing and phonation

Olfactory Nerve Function

Sensory Smell—coffee, cloves, peppermint

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: A) auricle. B) concha. C) outer meatus. D)mastoid process.

A) auricle

The salivary gland that is the largest and located in the cheek in front of the ear is the _____ gland. A) parotid B) Stensen's C) sublingual D) submandibular

A) parotid

The nurse is performing an ear examination of an 80-year-old client. Which of these would be considered a normal finding for the aging adult? A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membrane

A) A high-tone frequency loss

The nurse is completing a head to toe assessment on an aging adult client. Which of the following could the nurse do to conserve client energy? A) Arrange the sequence to allow as few position changes as possible B) Rush through the examination C) Complete the examination in one visit D) Maintain a confident manner

A) Arrange the sequence to allow as few position changes as possible

The nurse is assessing a client's hair. After assessing his gait, she has the client stand with his eyes closed to preform the romberg test in order to assess function of what area of his body? A) Cerebellum B) Temporal Lobe C) Spinal Cord D) Broca's Area

A) Cerebellum

During an assessment of a 20-year-old client with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: A)dehydration. B) irritation by gastric juices. C) a normal oral assessment. D) side effects from nausea medication.

A) Dehydration

After the health history has been obtained and before beginning the physical examination, the nurse should first ask the client to: A) Empty the bladder. B) Completely disrobe. C) Lie on the examination table. D) Walk around the room.

A) Empty the bladder

Which of the following are coordination and skilled movement assessments used to test cerebellar function? Select all that apply... A) Finger-to-finger test B) Stereognosis C) Patting the thighs D) Finger-to-nose test

A) Finger-to-finger test C) Patting the thighs D) Finger-to-nose test

A client has been in the hospital for 3 days. The nurse performs a bedside assessment in the morning. In the afternoon the client comes back to the floor after an operation. Which type of assessment would the nurse want to perform? A) Focused assessment B) Complete Head to Toe Assessment C) Functional Assessment D) Bedside Assessment

A) Focused assessment

The wife of a 65-year-old client tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe. A) frontal B) parietal C) occipital D) temporal

A) Frontal

Which of the following is true regarding the re-assessment of a hospitalized client? A) It is performed whenever the nurse sees changes in the client B) It is done to give a baseline so that changes can be detected early C) It is a complete head to toe acute care assessment D) Performed once, preferably in the early part of the day

A) It is performed whenever the nurse sees changes in the client

The nurse is assessing a client who may have hearing loss. Which of these statements is true concerning air conduction? A) It is the normal pathway for hearing. B) It is caused by the vibrations of bones in the skull. C) The amplitude of sound determines the pitch that is heard. D) A loss of air conduction is called a conductive hearing loss.

A) It is the normal pathway for hearing

What should the nurse assess before entering the client's room on morning rounds? A) Posted conditions, such as isolation precautions B) The client's input and output chart from the previous shift C) The client's general appearance D) The presence of any visitors in the room

A) Posted conditions, such as isolation precautions

When assessing the teeth and gums, which of the following would be a normal finding? A. The teeth are white and the gums are coral pink B. The gums are bleeding C. The adult client has 22 total teeth D. The upper and lower jaw are not aligned

A) The teeth are white and the gums are coral pink

The nurse is examining an older female client. Which of the following are expected changes that would be noted? Select all that apply A) The vagina is narrow and has lost its elasticity B) The labia & clitoris decrease in size C) Thinning pubic hair D) Decreased sexual drive

A) The vagina is narrow and has lost its elasticity B) The labia & clitoris decrease in size C) Thinning pubic hair

A client's wife tells the nurse that she is concerned because she noticed her husband has been having difficulty hearing normal conversation. The nurse suspects the client may have cranial nerve VIII damage. What tests would be appropriate for the nurse to use to confirm her suspicions of decreased hearing acuity? Select all that apply..... A) Whispered Voice Test B) Weber Test C) Rinne Test D) Romberg Test

A) Whispered Voice Test B) Weber Test C) Rinne Test

The nurse is doing an assessment on a 21-year-old client and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? A)"Are you aware of having any allergies?" B) "Do you have an elevated temperature?" C) "Have you had any symptoms of a cold?" D)"Have you been having frequent nosebleeds?"

A)"Are you aware of having any allergies?"

Which of the following would be considered subjective data? A. The patient states that he has clear discharge coming out of his ears. B. You note that the patient's ears are equal size and shape. C. The patient is unable to hear the words on the Whispered Voice Test. D. The patient's ear drum is a pearl gray color.

A. The patient states that he has clear discharge coming out of his ears.

Cranial Nerve 6

Abducens

Cranial Nerve 8

Acoustic

You are caring for a client admitted with c/o dizziness. What questions are appropriate to ask the client to elect health history information regarding the clients neuro system? Select all that apply.... A) Do you experience weakness? B) Do you experience numbness or tingling? C) Have you encountered any environmental or occupational hazards? D) Have you ever had a stroke or spinal cord injury?

All of the above A) Do you experience weakness? B) Do you experience numbness or tingling? C) Have you encountered any environmental or occupational hazards? D) Have you ever had a stroke or spinal cord injury?

A nurse is providing a client with information on anal and rectal health. Which of the following should the nurse include in educating the client? Select all that apply A) Avoid straining during defecation B) Eat a high fiber diet C) Avoid lifting extremely heavy items D) Keep anal area clean and dry

All of the above A) Avoid straining during defecation B) Eat a high fiber diet C) Avoid lifting extremely heavy items D) Keep anal area clean and dry

A nurse receiving report on a client admitted with symptoms of a stroke asks when the client's symptoms began. She knows this information is important in order to: Select all that apply... A) Reduce long term brain damage B) Reduce disability C) Provide appropriate treatment D) Save the person's life

All of the above A) Reduce long term brain damage B) Reduce disability C) Provide appropriate treatment D) Save the person's life

A nurse is conducting a complete neurological exam on a client who reports difficulty with speech. What other questions would be important for the nurse to ask this client? Select all that apply.... A) When did you first notice this symptom? B) How long did the symptoms last? C) Can you describe the symptoms? D) Any problems forming words?

All of the above: A) When did you first notice this symptom? B) How long did the symptoms last? C) Can you describe the symptoms? D) Any problems forming words?

The nurse is describing how to perform a testicular self-examination to a client. Which of these statements is most accurate? A) "A good time to examine your testicles is just before you take a shower." B) "If you notice an enlarged testicle or a painless lump, call your health care provider." C) "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency." D) "Perform a testicular exam at least once a week to detect the early stages of testicular cancer."

B) "If you notice an enlarged testicle or a painless lump, call your health care provider."

During a prostate examination of a 62 year old male, the nurse notices an immobile, tender nodule. A correct assessment of this finding is that this nodule is: A) Normal B) Abnormal

B) Abnormal

A female client comes in to the clinic complaining of perianal itching. Which of the following would NOT be appropriate to assist the client in preparing for a perianal examination? A) Instruct the client to inform you of any pain or discomfort during the exam. B) Assume that the client has had a vaginal exam before and has no questions. C) Ask the client if she would like a family member, friend or chaperone present. D) Have the client empty her bladder.

B) Assume that the client has had a vaginal exam before and has no questions.

The nurse is examining a male client. The client appears apprehensive. Which of the following actions can the nurse employ to reduce the client's anxiety? A) Use a soft, stroking touch B) Be confident and relaxed C) Talk to the client about his sexual practices D) Perform the examination quickly

B) Be confident and relaxed

A client presents to the ED in acute respiratory distress. How should the nurse proceed with gathering the health history? A) Collect all the information regardless of client condition B) Collect a mini-database and then complete the assessment once the distress is resolved C) Do not collect any information at this time D) Allow rest periods when needed

B) Collect a mini-database and then complete the assessment once the distress is resolved

The nurse is assessing the client's visual acuity using the snellen chart. The client's vision is 20/20. This indicates hat there is normal function of which cranial nerve? A) Cranial Nerve IV B) Cranial Nerve II C) Cranial Nerve VII D) Cranial Nerve V

B) Cranial Nerve II

The nurse is performing a neurological assessment on a 60 year old client who suffered a stroke and is experiencing left-sided weakness. She asks the client to stick her tongue out and move it from side to side. The nurse notes the client's tongue deviates to the left side and suspects damage to which cranial nerve? A) Cranial Nerve IX B) Cranial Nerve XII C) Cranial Nerve VIII D) Cranial Nerve V

B) Cranial Nerve XII

Which of the following are expected changes that can be seen in the older adult due to the loss of neurons in the brain and spinal cord limitation? Select all that apply.... A) Improvement in fine coordination and agility. B) Decreased muscle strength and agility. C) Decreased reaction time. D) Progressive decrease in cerebral blood flow.

B) Decreased muscle strength and agility. C) Decreased reaction time. D) Progressive decrease in cerebral blood flow.

The nurse is palpating the sinus areas. If the findings are normal, then the client should report which sensation? A) No sensation B) Firm pressure C) Pain during palpation D) Pain sensation behind eyes

B) Firm pressure

What is an advantage for using SBAR during staff communication? A) Provides a complete client health history B) Improves verbal communication and reduces medical errors C) Focuses on a comprehensive physical examination D) Avoids making recommendations

B) Improves verbal communication and reduces medical errors

During a neurological assessment, the nurse finds the following: asymmetry when the client smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air from one side only when the nurse presses against the puffed cheeks. This would indicate dysfunction of which of these cranial nerves? A) Motor component of IV B) Motor component of VII C) Motor and sensory components of XI D) Motor component of X and sensory component of VII

B) Motor component of VII

A graduate nurse asks a more experienced nurse when she should complete a neuro assessment during the course of her shift. An appropriate response would be: A) Neuro assessments should not be performed while assessing other body systems. B) Neuro assessments can be performed covertly. C) Neuro assessments should only be performed on admission. D) Neuro assessments should only be performed when a client complains of a headache.

B) Neuro assessments can be performed covertly.

Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the client.

B) Record the data as soon as possible after the interview and physical examination.

Which of the following is a true statement regarding the bedside assessment of the hospitalized client? A) Hospitalized clients require a complete head to toe screening exam every 24 hours B) The bedside assessment is a specialized assessment done at least every 12 hour shift C) The bedside assessment is the complete examination done with the first client encounter D) The bedside assessment only focuses on one body system

B) The bedside assessment is a specialized assessment done at least every 12 hour shift

The nurse is assessing a client who may have suffered a stroke. Which of these statements is true concerning areas of the brain? A) The cerebellum is the center for speech and emotions. B) The hypothalamus controls temperature and regulates sleep. C) The basal ganglia are responsible for controlling voluntary movements. D) Motor pathways of the spinal cord and brainstem synapse in the thalamus.

B) The hypothalamus controls temperature and regulates sleep.

A nurse is performing an assessment on an uncircumcised male client. She retracts the foreskin and remembers to return the skin to its original position. This action is performed to prevent which of the following from occurring? Select all that apply A) An erection B) Tissue loss C) Decreased circulation D) Amputation

B) Tissue loss C) Decreased circulation D) Amputation

In performing a whispered words test to assess hearing, which of these actions would the nurse do? A) Shield the lips so that the sound is muffled. B) Whisper a set of random numbers and letters and ask the patient to repeat them. C) Ask the patient to place his finger in his ear to occlude outside noise. D)Stand about 4 feet away to ensure that the patient can really hear at this distance.

B) Whisper a set of random numbers and letters and ask the patient to repeat them.

A client comes to the clinic complaining of neck and shoulder pain and is unable to turn her head, the nurse suspects damage to cranial nerve (CN) _____ and precedes with the examination by _____. A) XI; palpating the anterior and posterior triangles B) XI; asking the CLIENT to shrug her shoulders against resistance C) XII; percussing the sternomastoid and submandibular neck muscles D) XII; assessing for a positive Romberg sign

B) XI; asking the CLIENT to shrug her shoulders against resistance

After completing an assessment of a 60 year-old male client with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years.

B) colonoscopy every 10 years.

The primary purpose of the ciliated mucous membrane in the nose is to: A) warm the inhaled air. B) filter out dust and bacteria. C) filter coarse particles from inhaled air. D) facilitate movement of air through the nares.

B) filter out dust and bacteria

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: A) light pink with a slight bulge. B) pearly gray and slightly concave. C) pulled in at the base of the cone of light. D)whitish with a small fleck of light in the superior portion.

B) pearly gray and slightly concave.

During the interview, a client reveals to the nurse that she has been having a large amount of vaginal discharge and itching. She is worried that it may be a sexually transmitted infection. An appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"

C) "I'd like some information about the discharge. What color is it?"

During the assessment of the biceps reflexes, the nurse finds that a client's responses are normal bilaterally. The nurse would be correct in documenting this finding as _____. A) 3+ B) 1+ C) 2+ D) 4+

C) 2+

The nurse is assessing an 80-year-old client. Which of these findings would be expected for this client? A) Hypertrophy of the gums B) An increased production of saliva C) A decreased ability to identify odors D) Finer and less prominent nasal hair

C) A decreased ability to identify odors

A female client tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. The nurse suspects this could be due to dysfunction of which areas of the brain? A) Thalamus B) Brainstem C) Cerebellum D) Extrapyramidal tract

C) Cerebellum

A female client calls out to the nurse stating. "I see spiders on my arm". The nurse suspects the client is displaying symptoms of delirium. Which tool should the nurse use when assessing this client? A) Glasgow Coma Scale B) Neurologic Recheck Examination C) Confusion Assessment Method (CAM) D) Complete Neurologic Examination

C) Confusion Assessment Method (CAM)

A client tells the nurse he is having numbness not he left side of his face. The nurse asks him to close his eyes and touches a cotton ball to his forehead, chin, and both cheeks. The nurse is testing the function of which cranial nerve? A) Cranial Nerve III B) Cranial Nerve IV C) Cranial Nerve V D) Cranial Nerve VII

C) Cranial Nerve V

Which of the following statements is true regarding the olfactory nerve (CN 1)? The Olfactory Nerve is tested by having the client shrug their shoulder. B) The Olfactory Nerve is tested by having the client say "light, tight, dynamite." C) The Olfactory Nerve is tested by having the client smell a familiar substance like coffee, lemon or vanilla. D) The Olfactory Nerve is tested by having the client stick the tongue out.

C) The Olfactory Nerve is tested by having the client smell a familiar substance like coffee, lemon or vanilla.

The nurse is examining a client's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? A) Sticky honey-colored cerumen is a sign of infection. B) The presence of cerumen is indicative of poor hygiene. C) The purpose of cerumen is to protect and lubricate the ear. D) Cerumen is necessary for transmitting sound through the auditory canal.

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

A client has been shown to have sensorineural hearing loss. During the assessment, it would be important for the nurse to: A) speak loudly so he can hear the questions. B) assess for middle ear infection as a possible cause. C) ask the patient what medications he is currently taking. D) look for the source of the obstruction in the external ear.

C) ask the patient what medications he is currently taking.

A client with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the client that the middle ear functions to: A) maintain balance. B) interpret sounds as they enter the ear. C) conduct vibrations of sounds to the inner ear. D) increase amplitude of sound for the inner ear to function.

C) conduct vibrations of sounds to the inner ear.

The nurse is examining an older male client. Which of the following are expected changes that would be noted? A) loss of libido. B) increased pubic hair. C) decreased penis size. D) increased time for erection

C) decreased penis size.

The nurse is assessing a client in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? A)"We will need to get a biopsy and see what the cause is." B)"This is an overgrowth of hair and will go away in a few days." C)"This is a fungal infection caused by all the antibiotics you've received." D)"This is probably caused by the same bacteria you had in your lungs."

C)"This is a fungal infection caused by all the antibiotics you've received."

An 18-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of these findings would be consistent with an acute infection? A)Tonsils 1+/1-4+ and pink, same color as oral mucosa B)Tonsils 2+/1-4+ with small plugs of white debris C)Tonsils 3+/1-4+ with large white spots D)Tonsils 3+/1-4+ with pale coloring

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

The nurse is assessing the ear of an adult client. How should the nurse perform the examination? A. Pull the pinna down and insert scope B. Insert the scope straight into the ear C. Pull the pinna up and back and insert the scope D. Tilt the scope to the angle of the ear

C: Pull the pinna up and back and insert the scope.

Facial Nerve Function

Sensory Taste—anterior two thirds of tongue; sweet—sugar; salty; sour—lemon; bitter Motor Movement of forehead and mouth Raise eyebrows, show teeth, smile, and puff out cheeks

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" A correct response would be: A) "It depends. Do you smoke?" B) "A Pap test needs to be performed annually until you are 65 years of age." C) "If you have two consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30, if you have three consecutive normal Pap tests, then you may be screened every 3 years."

D) "After age 30, if you have three consecutive normal Pap tests, then you may be screened every 3 years."

The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report? A) "I'm worried that his gastrointestinal bleeding is getting worse." B) "We need an order for oxygen." C) "My name is Ms. Smith, and I'm giving the report on Mrs. X in room 1104." D) "He is 4 days postoperative, and his incision is open to air."

D) "He is 4 days postoperative, and his incision is open to air."

The nurse is taking the history of a client who may have a perforated eardrum. What would be an important question in this situation? A) "Do you ever notice ringing or crackling in your ears?" B) "When was the last time you had your hearing checked?" C) "Have you ever been told you have any type of hearing loss?" D) "Was there any relationship between the ear pain and the discharge you mentioned?"

D) "Was there any relationship between the ear pain and the discharge you mentioned?"

A 75 year old client with an enlarged prostate is concerned because he has trouble sleeping. He states, "I have to pee about 6 or 7 times a night and it just drips." A correct response would be: A) "You probably have a bladder infection. We'll need to give you antibiotics." B) This is a natural part of the aging process." C) "This is the way the kidney removes bacteria from the body." D) "You may want to cut back on drinking fluids about 3 hours before bedtime."

D) "You may want to cut back on drinking fluids about 3 hours before bedtime."

Which of the following ways does the electronic health record (EHR) increase client safety? A) Decrease transcription and prescribing errors B) Notify providers of medication interactions C) The provider must be physically present on the floor to write orders D) Both A & B

D) Both A & B

A nurse suspects hat her client may have suffered a stroke. Which tools can the nurse use to confirm her suspicions? A) R.A.C.E B) NIH Scale C) F.A.S.T D) Both B and C

D) Both B and C

A female client has just been diagnosed with Human papillomavirus (HPV) and genital warts. The nurse should counsel her to receive regular examinations because this virus places her at a higher risk for which disease process? A) Bladder Infection B) Uterine Prolapse C) Ovarian Cysts D) Cervical Cancer

D) Cervical Cancer

A female client is in the clinic with weakness in her left arm and leg that she has noticed for the past week. Which type of neurologic examination would be MOST appropriate for this client? A) Glasgow Coma Scale B) Neurologic Recheck Examination C) Neurologic Screening Examination D) Complete Neurologic Examination

D) Complete neurologic examination

The nurse is using the diagnostic positions test to assess her clients extra ocular eye movements. She notes parallel tracking of both eyes. She would be correct in documenting normal findings for which cranial nerve(s)? A) Cranial Nerve VII B) Cranial Nerve I C) Cranial Nerve II D) Cranial Nerves III, IV & VI

D) Cranial Nerves III, IV & VI

The nurse is assessing a client who has a hearing impairment. How should the nurse communicate with this client?  A) Use a low tone and speak slowly. B) Use a normal tone of voice and speak slowly. C) Speak loudly with a normal rate. D) Face the client and speak slowly.

D) Face the client and speak slowly.

All of the following is required equipment you would use for a complete head to toe assessment except: A) Tuning fork B) Platform scale with height attachment C) Stethoscope with bell and diaphragm end pieces D) Hoyer lift

D) Hoyer lift

The nurse is assessing the client's position sense by moving the client's fingers and toes in the up, down, and neutral position. The client is able to identify which position the nurse is moving the limbs. The test is called: A) Graphesthesia B) Extinctioçn C) Point location D) Kinesthesia

D) Kinesthesia

At the beginning of rounds, when the nurse enters the room, what should the nurse do first? A) Check the infusion pump settings for accuracy B) Check the intravenous infusion site for redness or swelling C) Offer the client something to drink D) Make eye contact with the client and introduce himself or herself as the client's nurse

D) Make eye contact with the client and introduce himself or herself as the client's nurse

The nurse is performing an assessment of a male client. Which of these statements is true about the testes? A) The lymphatics of the testes drain into the abdominal lymph nodes. B) The vas deferens is located along the inferior portion of each testis. C) The right testis is lower than the left because the right spermatic cord is longer. D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

A new graduate nurse asks a more experienced nurse why the initial assessment is done in the early part of the day. The nurse would respond: A) To get your charting done before the physician rounds B) To assess a client following procedures C) To have a more accurate assessment D) To get a baseline for your client so that changes can be detected early

D) To get a baseline for your client so that changes can be detected early

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The client: A) demonstrates ability to hear normal conversation. B) sticks tongue out midline without tremors or deviation. C) follows an object with both eyes without nystagmus or strabismus. D) moves the head and shoulders against resistance with equal strength.

D) moves the head and shoulders against resistance with equal strength.

Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X (Vagus)? A)Observe the patient's ability to articulate specific words. B)Observe the patient's ability to move the shoulders against resistance. C)Have the patient stick out the tongue and observe for tremors or pulling to one side. D)Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

D)Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

Optic Nerve Function

Sensory Visual acuity—Snellen chart (cover eye not being examined) Test for visual fields Examine with ophthalmoscope

Cranial Nerve 9

Glossopharyngeal

Cranial Nerve 12

Hypoglossal

Cranial Nerve 7

Facial

Abducens Nerve Function

Motor Inferior lateral eye movements (look to the side)

Trochlear Nerve Function

Motor Inferior lateral movement of the eye (look down at your nose)

Oculomotor Nerve Function

Motor Move eye up, down, and peripherally Test for accommodation Pupillary constriction Observe for ptosis of upper eyelid

Glossopharyngeal Nerve Function

Motor Swallowing and phonation Sensory Taste—posterior one third of tongue; see cranial nerve VII

Hypoglossal Nerve Function

Motor Tongue movement—protrude tongue, push tongue into the cheek

Spinal Nerve Function

Motor accessory Shoulder movement, shoulder shrug, head rotation—push against examiner's hand

Cranial Nerve 3

Oculomotor

Cranial Nerve 1

Olfactory

Cranial Nerve 2

Optic

Trigeminal Nerve Function

Sensory Corneal reflex Sensation of skin of the face (eyebrow, cheeks and chin) by using a wisp of cotton Motor Chewing, biting, lateral jaw movements (move jaw side to side)

Cranial Nerve 11

Spinal

Cranial Nerve 5

Trigeminal

Cranial Nerve 4

Trochlear

Cranial Nerve 10

Vagus