Ch 28 Complete HA Flashcards
An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers:
a. Posture.
b. Mobility.
c. Mood and affect.
d. Physical deformity.
b. Mobility.
he nurse is performing a vision examination. Which of these charts is most widely used for vision examinations?
a. Snellen
b. Shetllen
c. Smoollen
d. Schwellon
a. Snellen
After the health history has been obtained and before beginning the physical examination, the nurse should first ask the patient to:
a. Empty the bladder.
b. Completely disrobe.
c. Lie on the examination table.
d. Walk around the room.
a. Empty the bladder.
During a complete health assessment, how would the nurse test the patients hearing?
a. Observing how the patient participates in normal conversation
b. Using the whispered voice test
c. Using the Weber and Rinne tests
d. Testing with an audiometer
b. Using the whispered voice test
A patient states, Whenever I open my mouth real wide, I feel this popping sensation in front of my ears. To further examine this, the nurse would:
a. Place the stethoscope over the temporomandibular joint, and listen for bruits.
b. Place the hands over his ears, and ask him to open his mouth really wide.
c. Place one hand on his forehead and the other on his jaw, and ask him to try to open his mouth.
d. Place a finger on his temporomandibular joint, and ask him to open and close his mouth.
d. Place a finger on his temporomandibular joint, and ask him to open and close his mouth.
The nurse has just completed an examination of a patients extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves?
a. II, III, and VI
b. II, IV, and V
c. III, IV, and V
d. III, IV, and VI
d. III, IV, and VI
A patients uvula raises midline when she says ahh, and she has a positive gag reflex. The nurse has just tested which cranial nerves?
a. IX and X
b. IX and XII
c. X and XII
d. XI and XII
a. IX and X
During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with the successful performance of this action?
a. I
b. V
c. XI
d. XII
d. XII
A patient is unable to shrug her shoulders against the nurses resistant hands. What cranial nerve is involved with successful shoulder shrugging?
a. VII
b. IX
c. XI
d. XII
c. XI
During an examination, a patient has just successfully completed the finger-to-nose and the rapid- alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patients __________ function is intact.
a. Occipital
b. Cerebral
c. Temporal
d. Cerebellar
d. Cerebellar
- When the nurse performs the confrontation test, the nurse has assessed:
a. Extraocular eye muscles (EOMs).
b. Pupils (pupils equal, round, reactive to light, and accommodation [PERRLA]).
c. Near vision.
d. Visual fields.
d. Visual fields.
Which statement is true regarding the complete physical assessment?
a. The male genitalia should be examined in the supine position.
b. The patient should be in the sitting position for examination of the head and neck.
c. The vital signs, height, and weight should be obtained at the end of the examination.
d. To promote consistency between patients, the examiner should not vary the order of the assessment.
b. The patient should be in the sitting position for examination of the head and neck.
Which of these is included in an assessment of general appearance?
a. Height
b. Weight
c. Skin color
d. Vital signs
c. Skin color
The nurse should wear gloves for which of these examinations?
a. Measuring vital signs
b. Palpation of the sinuses
c. Palpation of the mouth and tongue
d. Inspection of the eye with an ophthalmoscope
c. Palpation of the mouth and tongue
The nurse should use which location for eliciting deep tendon reflexes?
a. Achilles
b. Femoral
c. Scapular
d. Abdominal
a. Achilles