HESI Compass: Moduel 2

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding?

NOTIFY THE PROVIDER! a bruit heard during auscultation of the abdominal aorta can indicate an aneurysm. Notify the provider and DO NOT PALPATE or PERCUSS. This poses a risk for rupture.

Myopia

Nearsightedness - Can't see far away

A client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data?

Normal ocular movement.

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding?

Nystagmus - Nystagmus is a fine oscillating movement, most notable around the iris. The nurse checks for nystagmus when assessing a client for ocular muscle weakness. Mild nystagmus at extreme lateral gaze is normal; nystagmus at any other position is not.

A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?

The nurse places their hands on the clients shoulders and asks the client to shrug against the resistance To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size. The nurse checks that these muscles are equal in strength by asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands.

Before examining the ear of an adult with an otoscope

The nurse should pull the pinna up and back. - For children under 3 pull the pinna back

Ophthalmoscope visualizes what?

The optic disk - Best for the INTERIOR of the eye - Conjunctiva, cornea, and iris can be viewed w/out this tool

Confrontation test

- Gross measure of peripheral vision - Nurse instructs client to cover one eye - The nurse covers the opposite eye - The nurse moves an object or finger into the midline - The client should say "now" when they see the object - When the nurse sees the object for the first time the patient should see it out if their peripheral vision

Complete database

- Health history - Physical examination - Initial visit with no poor knowledge need the COMPLETE story

Rinne test

- Test for hearing loss with a tuning fork - Differentiates sound transmitted through air conduction from those transmitted through bone

Episodic database

For short term and acute problems - Focused on 1 particular thing

A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse?

+ 2 4+, bounding pulse; 3+, increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the client's pulse as 2+.

Snellen chart for vision screening

- 20 feet away - Individual eyes - Then both eyes

A nurse performing a neurological examination is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve? A. Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear B. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face C. Asking the client to raise his or her eyebrows and looking for symmetry D. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle

A. Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear To test the cochlear portion of the acoustic nerve, the nurse has the client close the eyes and indicate when a ticking watch or rustling of the examiner's fingertips is heard as the stimulus is brought closer to the ear. To test the motor component of the trigeminal nerve, the nurse asks the client to clench the teeth and palpates the masseter muscles just above the mandibular angle. To test the sensory component of the trigeminal nerve (cranial nerve V), the nurse has the client identify light and sharp touch on both sides of the face. Asking the client to raise the eyebrows and watching for symmetry is one method of testing the function of the facial nerve (cranial nerve VII).

A 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy. The nurse who is interviewing the client should first: A. Assess the client's knowledge of available birth control methods B. Tell the client that for her age and lifestyle, birth control pills would be the easiest method of contraception C. Give the client written material about various birth control methods and ask her to read them and to call if she has any questions D. Inform the client that birth control methods cannot be discussed unless the client's boyfriend is present

A. Assess the client's knowledge of available birth control methods Learning occurs more readily when new information complements existing knowledge. Therefore it is important for the nurse to assess the client's level of knowledge of the subject matter. Although the use of written material assists in the learning process, this would not be the first nursing intervention. Telling the client that because of her age and lifestyle birth control pills would be the easiest method of contraception provides advice from the nurse's perspective and does not allow the client the opportunity to make her own decision. Telling the client that birth control methods cannot be discussed unless the client's boyfriend is present is incorrect and nontherapeutic.

A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by: A. Assessing visual acuity B. Assessing ocular movements C. Inspecting the eyelids for ptosis D. Assessing pupil constriction

A. Assessing visual acuity The optic nerve is assessed through the testing of visual acuity and visual fields by means of confrontation.

A mother brings her 18-month-old child to the clinic to receive the next scheduled vaccine. The child has previously received the following vaccines: three doses of the hepatitis B vaccine (at birth and 1 and 6 months of age); three doses of the diphtheria/tetanus/acellular pertussis (DTaP) vaccine (at 2, 4, and 6 months of age); four doses of Haemophilus influenzae type b (Hib) conjugate vaccine (at 2, 4, 6, and 12 months of age); three doses of inactivated poliovirus vaccine (IPV) (at 2, 4, and 6 months of age); one dose of measles/mumps/rubella vaccine (MMR) (at 12 months of age); varicella zoster vaccine at 12 months of age; and four doses of pneumococcal vaccine (at 2, 4, 6, and 12 months of age). After reviewing the child's immunization record, which scheduled vaccine does the nurse prepare to administer? A. DTaP B. MMR C. Hib D. IPV

A. DTaP DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Because the child has received only three doses of this vaccine, the DTaP should be administered. Hepatitis B vaccine is administered at birth and at 1 and 6 months of age. Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months. IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age. MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age. Varicella zoster vaccine is administered between 12 and 15 months of age. Pneumococcal vaccine is administered at 2, 4, and 6 months of age and at 12 to 15 months of age.

On assessing a client's skin, the nurse notes the presence of several large red-blue and purple areas on the client's body that do not blanch when pressure is applied. The nurse documents this finding as: A. Ecchymosis B. Petechiae C. Anasarca D. Psoriasis

A. Ecchymosis Ecchymosis refers to a large patch of capillary bleeding into the tissues (bruise). The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is noted as scaly erythematous patches with silvery scales on top that usually occur on the scalp, the outsides of elbows and knees, the low back, and the anogenital area. Bilateral edema or edema that is generalized over the entire body is known as anasarca. This finding is indicative of a central problem such as congestive heart failure or kidney failure. Petechiae are tiny purple or red spots that appear on the skin as a result of tiny hemorrhages within the dermal and subdermal areas.

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the: A. Fifth left interspace at the midclavicular line B. Second left interspace C. Left lower sternal border D. Second right interspace

A. Fifth left interspace at the midclavicular line The mitral valve is located in the area of the fifth left interspace, at the midclavicular line. The pulmonic valve is located in the area of the second left interspace. The aortic valve is located in the area of the second right interspace. The tricuspid valve is located in the area of the left lower sternal border.

A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips: A. Lateral to the extensor tendon of the big toe B. Behind the knee C. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines D. In the groove between the malleolus and the Achilles tendon

A. Lateral to the extensor tendon of the big toe The dorsalis pedis pulse is palpated lateral to and parallel with the extensor tendon of the big toe. The popliteal pulse is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. The femoral artery is located below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.

At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she states that: A. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down B. BSE must be performed every other month C. Monthly BSE is the only way to ensure early detection of breast cancer D. BSE is performed on the day menstruation begins

A. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down BSE is performed monthly and should be carried out after the menstrual period, on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. A woman who is not having menstrual periods should select a specific day of the month and perform BSE on that day each month. BSE is not the only way to detect early breast cancer. Women should get regular physical examinations and mammograms as prescribed. The woman is taught to inspect the breasts while standing in front of a mirror, to palpate the breasts while in the shower (because soap and water assist in palpation), and, finally, to perform palpation while lying supine.

A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion (ROM) of the cervical spine? A. Neck trauma B. Headache C. Muscle spasms D. Sinus infection

A. Neck trauma A nurse performing a musculoskeletal assessment would not test ROM in a client who has sustained neck trauma, which may have resulted in a cervical fracture. If a cervical fracture is present, further movement of the neck could result in spinal cord injury.

A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurse performs this assessment by: A. Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine" B. Auscultating the breath sounds over the peripheral lung fields C. Palpating for symmetric chest expansion D. Auscultating the breath sounds over the trachea and larynx

A. Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine" Palpation over the lung is used to assess tactile (vocal) fremitus. The nurse begins by palpating over the lung apices in the supraclavicular areas. The nurse compares vibrations from side to side as the client repeats the word "ninety-nine." To palpate for symmetric chest expansion, the nurse places the hands on the anterolateral wall, with the thumbs along the costal margins and pointing toward the xiphoid process. The client is asked to take a deep breath; as he or she does so, the nurse watches his or her thumbs move apart and watches for symmetry. Auscultation of breath sounds over the trachea and larynx is used to assess bronchial breath sounds. Auscultation of breath sounds over the peripheral lung fields is used to assess vesicular breath sounds.

A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures: A. Peripheral vision B. Color vision C. Distant vision D. Near vision

A. Peripheral vision

A nurse preparing to perform an abdominal assessment asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity? A. Tympany B. Borborygmus C. Dullness D. Hyperresonance

A. Tympany The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is supine. Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus (the term used to describe hyperperistalsis) may be noted on auscultation, not percussion. Hyperresonance is present with gaseous distention.

A nurse is preparing to listen to a client's breath sounds. The nurse should: A. Use the diaphragm of the stethoscope, holding it firmly against the client's chest B. Listen to the right lung, then the left lung C. Ask the client to lie down D. Ask the client to take shallow rapid breaths through the mouth

A. Use the diaphragm of the stethoscope, holding it firmly against the client's chest The nurse asks the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client is asked to breathe through the mouth a little more deeply than usual but is told to stop if he or she begins to feel dizzy. The nurse uses the flat diaphragm endpiece of the stethoscope, holding it firmly on the chest wall, and listens for at least one full respiration in each location, moving from side to side to compare sounds.

A nurse is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the nurse: A. Uses a tuning fork B. Asks the client to puff out the cheeks C. Checks the client's ability to clench the teeth D. Tests taste perception on the client's tongue

A. Uses a tuning fork Testing of cranial nerve VIII (acoustic nerve) entails checking hearing acuity by assessing the client's ability to hear normal conversation, assessing the client's performance on the whispered voice test, and performing the Weber and Rinne tuning fork tests. Asking the client to puff out the cheeks is used to test the function of cranial nerve VII (facial nerve).

A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?

Accommodation. Accommodation is adaptation of the eye for near vision. Movement of the ciliary muscles increases the curvature of the lens. To observe accommodation, the examiner notes convergence (motion toward) of the axes of the eyeballs and pupillary constriction.

20/80 vision

At 20 feet, someone sees what normal people see at 80 feet.

A nurse is describing the procedure for testicular self-examination (TSE) to a male client. Which statement should the nurse make to the client? A. "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency." B. "If you notice an enlarged testicle or a lump, you need to notify the physician." C. "A good time to examine the testicles is just before you take a shower." D. "Perform a testicular exam at least every 2 months to detect early signs of testicular cancer."

B. "If you notice an enlarged testicle or a lump, you need to notify the physician." During a shower or bath is the best time to examine the testes, because warm temperatures make the testes hang lower in the scrotum. The testes should feel round and smooth, without lumps. Self-examination should be performed monthly. The physician is to be notified immediately if any abnormalities are found.

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? A. Cranial nerves I and II B. Cranial nerves IX and X C. Cranial nerve XII D. Cranial nerve V

B. Cranial nerves IX and X The motor function of cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) is tested by depressing the tongue with a tongue blade and noting the pharyngeal movement as the client says "ah." Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex.

A nurse performing a neurological assessment is inspecting the client's eyelids for ptosis. The nurse checks the client for: A. Deviation of ocular movements B. Drooping C. Pupil dilation D. Pupil constriction

B. Drooping Ptosis, a drooping of the eyelids, can occur as a result of disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell palsy. Pupil dilation and constriction are checked with the use of a flashlight. Ocular movements are checked by leading the client's eyes through the six cardinal positions of gaze.

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expects to note if the bladder is full? A. Hypoactive bowel sounds B. Dull sounds C. An absence of bowel sounds D. Hyperresonance sounds

B. Dull sounds Normally a bladder is not percussible until it contains 150 mL of urine. If the bladder is full, dullness is heard over the symphysis pubis. Hyperresonance is present with gaseous distention of the abdomen. Bowel sounds are auscultated, not percussed.

A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse understands that this indicates: A. Full ROM with gravity eliminated (passive motion) B. Full ROM against gravity with some resistance C. Full ROM against gravity with full resistance D. Full range of motion (ROM) with gravity

B. Full ROM against gravity with some resistance Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction.

A nurse teaches a client about healthy dietary measures and explains the MyPlate food plan. The nurse determines that the client understands the information if the client says how many of his grains should be whole grains? A. Two-thirds B. One-half C. One-quarter D. One-third

B. One-half According to the MyPlate food plan, at least half of grains eaten daily should be whole grains. While it is acceptable to make more than half of your grains whole grains, MyPlate does not require it.

A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? A. Tubular B. Rustling C. Hollow D. Harsh

B. Rustling Vesicular breath sounds are rustling and sound like wind blowing through trees. Bronchial (tracheal) breath sounds are harsh, hollow, tubular sounds.

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct? A. Providing seating for the client so that the client faces a strong light B. Setting the room temperature at a comfortable level C. Placing a chair for the client across from the nurse's desk D. Setting up seating so that the client and nurse are not at eye level

B. Setting the room temperature at a comfortable level When preparing the physical environment for an interview with a client, the nurse sets the room temperature at a comfortable level. The nurse also provides privacy and sufficient lighting and removes distracting objects or equipment and noise from the environment. The distance between the client and the nurse should be 4 to 5 feet (1.2 to 1.5 meters) (twice arm's length). The nurse arranges the seating so that client and nurse are at eye level. Barriers (e.g., facing a client across a desk or table) are avoided.

A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over: A. Major bronchi B. The peripheral lung fields C. The xiphoid process D. The trachea and larynx

B. The peripheral lung fields Vesicular breath sounds are heard over the peripheral lung fields, where air flows through the smaller bronchioles and alveoli. Bronchovesicular breath sounds are heard over the major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Breath sounds are not heard over the xiphoid process.

A 35-year-old female client asks the clinic nurse when she should begin to have yearly mammograms. What does the nurse tell the client? A. Yearly mammograms are recommended starting at the age of 20 and continuing until menopause begins. B. Yearly mammograms are recommended starting at age 40. C. Yearly mammograms are not necessary unless there is a family history of breast cancer. D. Yearly mammograms are recommended starting at age 25.

B. Yearly mammograms are recommended starting at age 40. The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exam should be done about every 3 years for women in their twenties and thirties and every year for women 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-exam should be done monthly starting when a woman is in her twenties. The American Cancer Society also recommends that some women, because of their family history, a genetic tendency, or certain other factors, be screened with magnetic resonance imaging in addition to mammograms.

A nurse is providing instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in one week. Which statement does the nurse make to the client? A. "If you are menstruating, use pads instead of a tampon." B. "If you are having a vaginal discharge, obtain a sample of the discharge for inspection." C. "Avoid intercourse for 24 hours before the scheduled examination." D. "Get a douching kit from the pharmacy and douche 2 hours before the examination."

C. "Avoid intercourse for 24 hours before the scheduled examination." The Pap test is used to screen for cervical cancer. It is not performed during menses or if a heavy infectious discharge is present. The woman is instructed not to douche, have intercourse, or insert anything into the vagina in the 24 hours before the test.

During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client? A. "Don't worry about the discharge. Some vaginal discharge is normal." B. "Have you been engaging in unprotected sexual intercourse?" C. "I need some more information about the discharge. What color is it?" D. "When was your last gynecological checkup?"

C. "I need some more information about the discharge. What color is it?" If the client says that she has had some vaginal drainage, the nurse should obtain additional data about the discharge. The nurse would ask about the character and color of the discharge, when the discharge began, any factors associated with the discharge, medications being taken, and self-care behaviors. Normal discharge is sparse, clear, or cloudy and is always nonirritating. Unprotected sexual intercourse suggests that the discharge is associated with a STI and would cause more concern on the part of the client. Telling the client not to worry is a nontherapeutic communication technique. Asking about her last gynecological checkup may be an appropriate question but is not related to the subject of the question.

A nurse conducting a physical assessment of a client plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal: A. Loss of hearing acuity B. A problem with distant hearing C. A problem with balance D. A problem discriminating high-pitched and low-pitched sounds

C. A problem with balance The Romberg test, a balance test, is used to assess cerebellar function. The client stands with his or her feet together and arms at the side. Once he or she is in a stable position, the client is asked to close the eyes and hold the position for about 20 seconds. Normally the client can maintain posture and balance, although slight swaying may occur. Hearing acuity, including distant hearing and the ability to discriminate high- and low-pitched sounds, is assessed with the use of the voice and tuning-fork tests.

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: A. Normal egophony B. Normal whispered pectoriloquy C. Abnormal bronchophony D. Abnormal vesicular breath sounds

C. Abnormal bronchophony The quality of voice resonance can be performed by testing for the presence of bronchophony, egophony, and whispered pectoriloquy. In bronchophony, the nurse asks the client to repeat the word "ninety-nine" as the nurse listens to the client's chest with a stethoscope. Normal voice transmission is soft, muffled, and indistinct. The nurse normally hears sound through the stethoscope but cannot distinguish exactly what is being said. A pathologic condition that increases lung density enhances the transmission of voice sounds; in such a case, the nurse will hear "ninety-nine" clearly.

A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are: A. Normally heard in the lungs B. Hollow sounds heard over the trachea and larynx C. Abnormal sounds that should not be heard in the lungs D. Rustling sounds heard over the peripheral lung fields

C. Abnormal sounds that should not be heard in the lungs Adventitious breath sounds are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused when moving air collides with secretions in the tracheobronchial passageways or when previously deflated airways pop open.

A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? A. A tuning fork B. A wisp of cotton C. Coffee D. An ophthalmoscope

C. Coffee To assess the function of cranial nerve I (olfactory nerve), the nurse tests the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a nonnoxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint.

A nurse performing a cranial nerve assessment is testing the function of the oculomotor, trochlear, and abducens nerves. Which of the following parameters does the nurse check to determine the function of these nerves? A. Corneal reflex B. Facial symmetry C. Eye movements D. Tongue symmetry

C. Eye movements Testing of the oculomotor, trochlear, and abducens nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation, as well as testing of extraocular movements through the cardinal positions of gaze.

During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing? A. Abducens B. Vagus C. Facial D. Oculomotor

C. Facial Assessment of cranial nerve VII (facial nerve) involves noting mobility and symmetry as the client smiles, frowns, closes the eyes tightly (against the nurse's attempt to open them), lifts the eyebrows, shows the teeth, and puffs out the cheeks. Cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) are tested together. Testing the motor function of these nerves entails depressing the client's tongue with a tongue blade and noting pharyngeal movement as the client says "ah" and touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Testing of the abducens, oculomotor, and trochlear nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and testing extraocular movements through the cardinal positions of gaze.

A nurse performing a musculoskeletal assessment of a client with suspected carpal tunnel syndrome plans to perform the Phalen test. The nurse should ask the client to: A. Dorsiflex the foot B. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds D. Plantarflex the foot

C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.

A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by: A. Palpating the carotid artery in the upper third of the neck B. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits D. Palpating both arteries simultaneously to compare amplitude

C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits To assess the carotid artery, the nurse uses the techniques of palpation and auscultation. The nurse palpates each carotid artery medial to the sternomastoid muscle in the neck. The nurse should avoid putting pressure on the carotid sinus higher in the neck because of the risk of excessive vagal stimulation, which could slow the heart rate. The nurse should palpate one artery at a time to avoid compromising arterial blood flow to the brain. The nurse should auscultate each carotid artery for the presence of a bruit. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally a bruit is not present. The nurse should lightly place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath briefly so that tracheal breath sounds do not mask or mimic a carotid artery bruit.

A nurse is assisting the physician in performing transillumination of a client's scrotum. The nurse prepares for this procedure by: A. Instructing the client to take several deep breaths and bear down B. Telling the client that the procedure is very uncomfortable but that the discomfort will only last for a few moments C. Obtaining a flashlight and darkening the room D. Instructing the client to drink three glasses of water

C. Obtaining a flashlight and darkening the room Transillumination of the testes is a painless procedure that is performed when swelling or a lump is noted on palpation. After the room is darkened, a strong flashlight is shined from behind the scrotal contents. Normal scrotal contents do not appear on transillumination. Instructing the client to drink fluids or to take deep breaths and bear down is not necessary.

A nurse reviewing a client's healthcare record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the nurse determine that the client has? A. Rotator cuff lesions B. Carpal tunnel syndrome C. Osteoarthritis D. Scoliosis

C. Osteoarthritis Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes.

A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign? A. Asking the client to hold the hands back to back while flexing the wrist 90 degrees B. Checking for repetitive movements in the joints C. Percussing at the location of the median nerve D. Testing the strength of each muscle joint

C. Percussing at the location of the median nerve The Tinel sign is elicited with direct percussion in the location of the median nerve at the wrist. The test produces no symptoms in the normal hand. In the presence of carpal tunnel syndrome, percussion of the median nerve produces burning and tingling along its distribution (Tinel sign).

A nurse reviewing a client's record notes documentation that the client has melena. How does the nurse detect the presence of melena? A. By checking the client's urine for a decrease in output B. By checking the client's bowel movements for diarrhea C. By checking the client's urine for blood D. By checking the client's stool for blood

D. By checking the client's stool for blood Melena is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

A nurse reviewing the physical assessment findings in a client's healthcare record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has? A. Scoliosis B. Bone deformity C. Heberden nodules D. Carpal tunnel syndrome

D. Carpal tunnel syndrome The Phalen test is performed to check for the presence of carpal tunnel syndrome. The client is asked to hold the hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen test reproduces the numbness and burning experienced by a client with carpal tunnel syndrome.

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? A. Cranial nerve IX B. Cranial nerve V C. Cranial nerve X D. Cranial nerve XII

D. Cranial nerve XII To test cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue. The nurse looks for a forward thrust in the midline as the client sticks out the tongue.

A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which of the following topics does the nurse ask the client about first? A. Her sexual history B. The presence of vaginal drainage C. Her obstetrical history D. Her menstrual history

D. Her menstrual history The nurse should begin collecting subjective data by asking the client about her menstrual history, because this information is usually nonthreatening to the client. Questions about sexual history, obstetrical history, and the presence of vaginal discharge would be asked, but this information may be perceived by the client as more sensitive and the questions more threatening.

A nurse performing a physical examination is assessing the client for costovertebral angle tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse interprets this finding as most indicative of: A. Liver enlargement B. Ovarian infection C. Spleen enlargement D. Kidney inflammation

D. Kidney inflammation When assessing for costovertebral angle tenderness, the nurse is checking for kidney tenderness. Sharp pain that occurs on percussion of the costovertebral angle indicates inflammation of the kidney or paranephric area. To assess the kidney, the nurse places one hand over the 12th rib, at the costovertebral angle, on the back. The nurse then thumps that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain.

A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client? A. Lithotomy B. Standing C. Supine D. Left lateral

D. Left lateral A female client is placed in the left lateral position for a rectal examination. If the examiner is examining the genitalia as well as the rectum, the woman is placed in the lithotomy position. A male client is placed in the left lateral or standing position. It would be difficult to perform a rectal examination on a client in the supine position.

A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination? A. Prone B. Left side-lying C. Sims D. Lithotomy

D. Lithotomy An internal gynecological examination is performed with the client in the lithotomy position. In this position, the client is supine, with the feet in stirrups, the knees apart, and the buttocks at the end of the examining table. The client is draped so that only the vulva is exposed.

A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if cholecystitis is present? A. McBurney sign B. Homan sign C. Blumberg sign D. Murphy sign

D. Murphy sign The Murphy sign is an indicator of gallbladder disease. The client is asked to inhale while the examiner's fingers are hooked under the liver border, at the bottom of the rib cage. Inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed.

A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the following actions does the nurse ask the client to take to aid assessment of this nerve? A. Smiling B. Clenching the teeth C. Identifying by taste a substance placed on the back of the tongue D. Shrugging the shoulders against the nurse's resistance

D. Shrugging the shoulders against the nurse's resistance To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve).

During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of the: A. Oculomotor nerve B. Abducens nerve C. Trochlear nerve D. Trigeminal nerve

D. Trigeminal nerve To test the motor function of cranial nerve V (trigeminal nerve), the nurse assesses the muscles of mastication by palpating the temporal and masseter muscles as the client clenches the teeth. The nurse tries to separate the jaws by pushing down on the client's chin. Normally the nurse cannot separate the jaws. Testing of the trochlear, abducens, and oculomotor nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and assessing extraocular movements through the cardinal positions of gaze.

A nurse performing an abdominal assessment is preparing to auscultate for bowel sounds. The nurse: A. Listens for at least 1 minute before deciding that bowel sounds are absent B. Begins in the right lower quadrant C. Holds the stethoscope firmly and deeply against the skin D. Uses the bell end of the stethoscope

D. Uses the bell end of the stethoscope

Ptosis

Drooping of the eyelid.

During a physical assessment, the client tells the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing?

Dysphagia. Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia is a loss of appetite. Eructation is belching. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid.

Follow up database

Evaluates the status of a prior established problem at a regular interval.

Hyperopia

Farsightedness - Can't see up close

When a nurse palpates the sinus areas of a client. A normal finding is when the client reports?

Firm pressure - No pain - No headache

While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which of the following findings does the nurse expect to note when auscultating the client's bowel sounds?

Hyperactive bowel sounds. Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach.

Performing an abdominal assessment, a nurse notes tenderness while lightly palpating a client's right lower quadrant. The nurse determines that this finding is most likely associated with?

Inflammation of the appendix. The appendix is located in the right lower quadrant. The spleen is a soft mass of lymphatic tissue located on the posterolateral wall of the abdominal cavity, immediately under the diaphragm. The pancreas is a soft lobular gland located behind the stomach. The liver fills most of the right upper quadrant and extends over to the left midclavicular line.

First place the nurse puts the tuning fork to perform a rinne test

On the clients mastoid bone - Just behind the earlobe

A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination?

One week after menstruation begins. BSE should be performed after the menstrual period, on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. The pregnant woman or menopausal woman who is not having menstrual periods is taught to select a specific day to examine the breasts every month.

Exophthalmos

Protrusion of the eyeball.

Photophobia

Sensitivity to light.

A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of?

The radial and ulnar arteries The nurse would perform the Allen test to determine the patency of the radial and ulnar arteries. The nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While the nurse is applying pressure, the client is asked to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used to obtain a blood specimen.

An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse concludes that?

This is normal cardiac output. In the normal resting adult, the heart pumps between 4 and 6 L of blood per minute throughout the body. This cardiac output equals the volume of blood in each systole (called stroke volume) multiplied by the number of beats per minute. Therefore a cardiac output of 5 L/min is a normal cardiac output.

What tool does the nurse use to perform the Weber test?

Tuning fork Tuning fork tests measure hearing by way of air conduction or by bone conduction, in which sound vibrates through the cranial bones to the inner ear. The Weber test is a tuning fork test that is performed when the client reports hearing better with one ear than with the other. In the Weber test, a vibrating tuning fork is placed in the midline of the client's skull and the client is asked whether the tone sounds the same in both ears or better in one. The client should hear the tone by bone conduction through the skull, and it should sound equally loud in both ears. The otoscope, reflex hammer, and stethoscope may be used when performing the physical exam but are not needed to perform the Weber test.

The nurse performing a voice test would have a client repeat which kind of words?

Whisper 1 to 2 feet away from the ear being tested. - Client has the other hear covered - Nurse has their lips covered

A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by?

Wrapping the tape measurer around the widest point of the clients lower leg. The nurse uses a nonstretchable tape measure to measure the calf at its widest point, taking care to measure the opposite leg in exactly the same place, the same number of centimeters down from the patella or other landmark.

Scleral icterus

Yellowing of the sclera.