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health assessment > exam 3 > Flashcards

exam 3 Flashcards

1
Q

The nurse is assessing the ear of an adult client. How should the nurse perform the examination?

A

Pull the pinna up and back and insert the scope.

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2
Q

Which of the following would be considered subjective data?

A

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

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3
Q

The nurse is assessing a client who has a hearing impairment. How should the nurse communicate with this client?

A

Face the client and speak slowly.

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4
Q

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

A

Pearly gray and slightly concave.

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5
Q

The nurse needs to pull the portion of ear that consists of movable cartilage and skin down and back when administering ear drops. This portion of the ear is called the:

A

Auricle

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6
Q

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

Conduct vibrations of sounds to the inner ear.

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7
Q

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.

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8
Q

In performing a whispered words test to assess hearing, which of these actions would the nurse do?

A

Whisper a set of random numbers and letters and ask the client to repeat them.

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9
Q

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.

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10
Q

The nurse is examining a client’s ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

A

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

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11
Q

A client has beens shown to have sensorineural hearing loss. During the assessment, it would be important for the nurse to:

A

Ask the client what medications he is currently taking.

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12
Q

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

“Was there any relationship between the ear pain and the discharge you mentioned?”

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13
Q

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 3+/1-4+ with large white spots.

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14
Q

The salivary gland that is the largest and located in the cheek in front of the ear is the ____ gland.

A

parotid.

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15
Q

The nurse is assessing an 80-year-old client. Which of these findings would be expected for this client?

A

A decreased ability to identify odors.

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16
Q

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

dysphasia.

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17
Q

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 client?

A

“Are you aware of having any allergies?”

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18
Q

Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X (Vagus)?

A

Ask the client to say “ahhh” and watch for movement of the soft palate and uvula.

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19
Q

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 concerns, what would the nurse say?

A

“This is a fungal infection caused by all the antibiotics you’ve received.”

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20
Q

The primary purpose of the ciliated mucous membrane in the nose it to:

A

Filter out dust and bacteria.

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21
Q

The nurse is palpating the sinus areas. If the findings are normal, then the client should report which sensation?

A

Firm pressure.

22
Q

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.

23
Q

The two sinuses that can be directly palpated are?

A

Frontal and Maxillary

24
Q

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

25
Q

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

26
Q

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 nerves IX and X

27
Q

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 hypothalamus controls temperature and regulates sleep.

28
Q

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

moves the head and shoulders against resistance with equal strength

29
Q

during the history, a client tells the nurse that “it feels like the room is spinning around me.” the nurse would document this as:

A

vertigo

30
Q

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

complete neurologic examination

31
Q

during a neurological assessment, the nurse finds the following: asymmetry when the client smiles or frowns, uneven lifting of eyebrow, 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 VII

32
Q

a female client tells the nurse that she has been very unsteady and has had difficult in maintaining her balance. the nurse suspects this could be due to dysfunction of which area of the brain?

A

cerebellum

33
Q

during the assessment of the biceps reflexes, the nurse finds that a client’s responses are normal bilaterally. the nurse would be correct in document this finding as ___+

A

2+

34
Q

a graduate nurse asks a more experienced nurse when she should complete a neurologist assessment during the course of her shift. an appropriate response would be:

A

neuro assessments can be performed covertly

35
Q

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?
How long did the symptoms last?
Can you describe the symptoms?
Any problems forming words?

36
Q

a client tells the nurse he is having numbness on the left side of his face. the nurse asks him to close his eyes and touches a cocoon ball to his forehead, chin, and both cheeks. the nurse is testing the function of which cranial nerve?

A

cranial nerve V

37
Q

a nurse suspects that her client may have suffered a stroke. which tools can the nurse use to confirm her suspicious?

A

R.A.C.E

F.A.S.T

38
Q

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
reduce disability
provide appropriate treatment
save the person’s life

39
Q

a female client calls out to the nurse staffing, “I see spiders on my arm.” The nurse suspects that client is displaying symptoms of delirium. which tool should the nurse use when assessing this client?

A

The confusion assessment method (CAM)

40
Q

you are caring for a client admitted with c/o dizziness. what questions are appropriate to ask to elicit health history information regarding the client’s neuro system? SELECT ALL THAT APPLY

A

do you experience weakness?
do you experience numbness or tingling?
have you encountered any environmental or occupational hazards?
have you ever had a stroke or spinal cord injury?

41
Q

after assessing a client’s gait, the nurse has the client stand with his eyes closed to perform the Romberg test in order to assess function of what area of his body?

A

cerebellum

42
Q

the nurse is assessing a client’s visual acuity using the Snellen chart. The client’s vision is 20/20. this indicates that there is normal function of which cranial nerve?

A

cranial nerve II

43
Q

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 X

44
Q

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 SUSPICIONS OF DECREASED HEARING ACUITY? SELECT ALL THAT APPLY

A

whispered voice test
weber test
rinne test

45
Q

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 XII

46
Q

THE NURSE IS USING THE DIAGNOSTIC POSITIONS TEST TO ASSESS HER CLIENT’S EXTRAOCULAR EYE MOVEMENTS. SHE NOTES PARALLEL TRACKING OF BOTH EYES. SHE WOULD BE CORRECT IN DOCUMENTING NORMAL FINDINGS FOR WHICH CRANIAL NERVE(S)?

A

cranial nerves III, IV, and VI

47
Q

WHICH OF THE FOLLOWING ARE COORDINATION AND SKILLED MOVEMENT ASSESSMENTS USED TO TEST CEREBELLAR FUNCTION? SELECT ALL THAT APPLY

A

finger-to-finger test
patting the thighs
finger-to-nose test

48
Q

WHICH OF THE FOLLOWING STATEMENTS IS TRUE REGARDING THE OLFACTORY NERVE (CN I)?

A

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

49
Q

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

decreased muscle strength an d agility
decreased reaction time
progressive decrease in cerebral blood flow

50
Q

A NURSE IS ASSESSING A CLIENT RECENTLY DIAGNOSED WITH PARKINSON’S DISEASE. WHAT ABNORMAL BODY MOVEMENTS ARE TYPICALLY ASSOCIATED WITH THIS DISEASE?

A

resting tremors

51
Q

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

kinesthesia

52
Q

A CLIENT comes to the clinic complaining of neck and shoulder pain and is unable to turn his head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____.


A

XI; asking the CLIENT to shrug his shoulders against resistance

health assessment (4 decks)

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