NR 302 Final Exam Review
A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile remits. Which action by the nursing student indicated a need for further teaching? 1. Palpating over the lung apices in the supraclavicular area 2. Asking the client to repeat the word ninety-nine during palpation 3. Palpating over the breast tissue to assess and compare vibrations from 1 side to the other 4. Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine
3. Palpating over the breast tissue to assess and compare vibrations from 1 side to the other bc sound will be muffled
A client is diagnosed with external otitis (swimmers ear). Which finding would the nurse expect to note on the assessment of the client? 1. A wider than normal ear canal 2. A pearly gray tympanic membrane 3. Redness and swelling in the ear canal 4. An excessive amount of cerement lodged in the ear canal
3. Redness and swelling in the ear canal
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminishe
3. Wheezes high pitched squeaking sound
The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? 1. You have normal vision 2. You have some degree of blindness 3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft 4. You can read at a distance of 30 ft what a person with normal vision can read at 20 ft
3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft
Leukoplakia
chalky white, thick, raised patch on sides of tongue; precancerous does not scrape off. chronic smokers
Annular Lesions
circular, begins in center and spreads to periphery
atelectasis
collapsed lung
When assessing pupillary light reflex, the nurse advances a light to the pt's right eye, approaching from the side. The nurse notes that the right pupil _________, and the left pupil simultaneously ________ also known as _________________
constricts, constricts, accomodation
strabismus
crossed eyes
When assessing for accommodation, a patient's pupils will ___ when focusing on a distant object versus ______ and _______ when the patient focuses on a near object
dilate, converge and constrict
kyphosis
excessive outward curvature of the spine, causing hunching of the back. can be normal part of aging
Snellen Eye chart
eye chart 20 feet
Cranial nerve III, IV, VI
eye movements
clubbing of nails
finding in the nails that indicates chronic hypoxia 180 degrees
Macule
flat, colored spot on the skin (freckle)
nystagmus
Involuntary rapid eye movements
leukoedema
benign, milky, bluish-white opaque appearance of the buccal mucosa that occurs commonly in African Americans
vesicle
blister
Ecchymosis
bruise
Apex of lungs
top of lungs
Hypothyroidism
underactivity of the thyroid gland (cold intolerance, edematous face, cool skin, slow reflexes
Cranial Nerve II
visual acuity, pupillary light reflex
The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this exam? 1. Pull pinna up and back before inserting the speculum 2. Pull the earlobe down and back before inserting speculum 3. Tilt the client's head forward and down before inserting the speculum 4. Use the smallest speculum available to decrease discomfort
1. Pull pinna up and back before inserting the speculum
The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? 1. The major bronchi 2. The trachea and larynx 3. The peripheral lung fields 4. The lower posterior thorax
1. The major bronchi inspiratory=expiratory
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? 1. A tuning fork 2. A stethoscope 3. A tongue blade 4. A reflex hammer
1. A tuning fork
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. Increasing rate and depth of respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration
1. Increasing rate and depth of respirations with periods of apnea. pg. 434
The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? 1. Number of pack-years 2. Desire to quit smoking 3. Brand of cigarettes used 4. Number of past attempts to quit smoking
1. Number of pack-years how heavy of a smoker were they
The nurse performing a neurological exam is assessing eye movement to evaluate cranial nerves III, IV, VI. Using a flashlight, the nurse would perform which action to obtain assessment data? 1. turn the flashlight on directly in front of the eye and watch for a response 2. Ask the client to follow the flashlight through the 6 cardinal positions of gaze 3. instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye 4. Check pupil size, then ask the client to alternate looking at the flashlight and the examiner's finger
2. Ask the client to follow the flashlight through the 6 cardinal positions of gaze
The nurse in a health care clinic is preparing to test a client for accommodation, Initially, the nurse should ask the client to take which action? 1. Focus on a close object 2. Focus on a distance object 3. Close 1 eye and read letters on a chart 4. Raise 1 finger when the sound is heard
2. Focus on a distance object pupils will dilate
The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve) Which technique should the nurse implement to test the motor function of this nerve? 1. Ask the client to puff out the cheeks 2. Separate the client's jaw by pushing down on the chin 3. Place small amount of sugar on the client's tongue and ask him or her to identify the taste 4. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin
2. Separate the client's jaw by pushing down on the chin 4- spinal accessory 1, 3- facial nerve
The nurse is testing the extra ocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1. Test corneal reflexes 2. Test 6 cardinal positions of gaze 3. Test visual acuity, using Snellen eye chart 4. Test sensory function by asking client to close the eyes and then lightly touching the forehead, cheeks, chin
2. Test 6 cardinal positions of gaze
A client diagnosed with conductive hearing loss (physical obstruction) asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1. A deficit in the cochlea 2. A deficit in cranial nerve VIII 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex
3. A physical obstruction to the transmission of sound waves
Skin Melanoma Assessment
ABCDE Assymetry Border Color Diameter
scorbutic gums
Deficiency of vitamin C. Gums are swollen, ulcerated and bleeding due to vitamin-C induced defects in oral epithelial basement membrane and periodontal collagen fiber synthesis.
Identify the heart sounds that can be auscultated at the landmark highlighted below:
Erb's Point, 3rd intercostal space left side
barrel chest
a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema. 1:1 AP transverse
cheilosis
a disorder of the lips characterized by crack-like sores at the corners of the mouth
migraine headache
a headache characterized by throbbing pain on one side of the head
presbycusis
age related hearing loss
cranial nerve xi
ask patient to shrug shoulders
Impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture
VIII
hearing
Presbyopia
impairment of vision as a result of old age
Bronchial lung sounds
inspiration < expiration high pitched loud
vesicular
inspiration > expiration soft sound
Bronchovesicular
inspiration= expiration. moderate pitch
confluent
lesions run together
Zosteriform
linear shape of skin lesion along a nerve route
apex of heart
lower tip of the heart
Inspect Palpate Percuss Auscultate
order
Hyperthyroidism
overactive thyroid condition (goiter, exophthalmus, fatigue, weight loss, muscle cramp, tachycardia, heat intolerance)
cluster headache
pain is in and around one eye
Tension headache
pain is like a band squeezing the head
pallor
paleness (anemia)
fremitus
palpable vibration
pustule
papule containing pus
papule
pimple
Magenta tongue
riboflavin deficiency
primary vs secondary lesions
secondary are crusts
Cranial Nerve VII: Facial
smile
otitis externa
swimmers ear
cranial nerve ix and x
tell patient to say ahhh
Rinne test
test for conductive hearing loss
Weber test
test for sensorineural hearing loss
Bronchophony
the spoken voice sound heard through the stethoscope, which sounds soft, muffled, and indistinct over normal lung tissue
