Fall Semester Flashcards
During an otoscopic assessment, the nurse notes the presence of large amounts of cerumen in the client’s external canal. The nurse knows:
Cerumen helps to lubricate and protect the ear
A 60 year-old client tells the nurse that he has noticed a decrease in his hearing. The nurse knows that the age-related changes of the ear that likely are contributing to the decrease in his hearing are the result of:
Presbycusis
A client reports a family history of ear problems and hearing loss and is concerned about aging deafness. The most appropriate response by the nurse is:
“Hearing loss can be hereditary . Have you noticed any changes in your hearing?”
The nurse is preparing to use the otoscope to visualize the auditory canal and tympanic membrane of an adult client. Which of the following is most appropriate?
Pull the pinna up and back
Cranial nerve IV is known as
Trochlear
Cranial nerve II’s function is eyesight
True
This cranial nerve arises from the cranial and spinal roots which controls swallowing movements and governs movement of the head and shoulders
XI
Cranial nerve __ moves the eyeballs/eyelids and adjusts the pupil and lens of the eye
III
Cranial nerves __ move the eyeballs
III, IV, VI
Vestibulocochlear nerve (cranial nerve VIII) is responsible for auditory
True
During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury
Inserting the otoscopic inferiorly into the distal portion of the external canal
If the client reports loss of short-term memory, the nurse would assess this using which one of the following
Ask the client to describe how he or she arrived at this location
While assessing a patient’s lower extremities, the nurse notes edema around the feet and ankles. When the area is depressed, it lasts for more than 1 minute before the shape returns. How would the nurse document this?
3+ pitting edema
When performing an assessment, the nurse wants to determine circulation. The nurse would anticipate finding which of the following?
Capillary refill of less than 2 seconds of the extremeties
The most commonly used test for accurate measure of visual acuity is which of the following?
Snellen Eye Chart
