Week 2 Material + EAQ 2

Question 1

Methods of nose, mouth, throat assessment include:

Answer 1

inspection
palpation

Question 2

Pale lips might be seen with:

Answer 2

anemia

Question 3

Cracked/dry lips are associated with

Answer 3

dehydration
exposure to wind/cold

Question 4

Angular Cheilitis or cracks and redness in the corners of the mouth can occur with

Answer 4

Iron or vitamin B deficiency

Question 5

Lesions on/around lips can be caused by:

Answer 5

Herpes simplex virus
skin cancer
trauma

Question 6

Lip swelling can be related to

Answer 6

allergic reaction or injury

Question 7

Hyperplasia of gums associated with

Answer 7

Periodontal disease
medication side effects

Question 8

red/bleeding gums associated with

Answer 8

Gingivitis or hormonal abnormalities

Question 9

Beefy red tongue associated with

Answer 9

Iron or vitamin B deficiency

Question 10

Hairy tongue is associated with

Answer 10

fungal overgrowth from antibiotic therapy

Question 11

A nurse is assessing a patient’s neck. Which of the following is considered an expected finding?

A. Jugular vein distention
B. Midline trachea
C. Carotid artery prominence
D. Thyroid enlargement

Answer 11

B. Midline trachea

Question 12

Which symptom found when examining the head would be a cause for concern?

A. Symmetrical features at rest
B. Even distribution of hair
C. Bruits in the temporal arteries
D. Symmetrical features with movement

Answer 12

C. Bruits in the temporal arteries

Question 13

What information should be included when entering documentation of an enlarged lymph node?

A. Location, size, and shape
B. Consistency and tenderness
C. Discreteness and movability
D. All of the above

Answer 13

D. All of the above

Question 14

When assessing lymph nodes, it is important to do which of the following?

A. Compare lymph nodes bilaterally.
B. Use the thumbs to palpate.
C. Provide privacy for the patient.
D. Both comparing the lymph nodes bilaterally and providing privacy for the patient.

Answer 14

D. Both comparing the lymph nodes bilaterally and providing privacy for the patient.

Question 15

Which lymph nodes are located in the depression above and posterior to the medial condyle of the humerus?

A. Axillary lymph nodes
B. Inguinal lymph nodes
C. Epitrochlear lymph nodes
D. Parotid lymph nodes

Answer 15

C. Epitrochlear lymph nodes

Question 16

Which of the following indicates normal respiratory function?

A. Symmetrical chest expansion
B. Nasal flaring
C. Use of accessory muscles
D. Lip pursing

Answer 16

A. Symmetrical chest expansion

Question 17

When palpating the thorax, which of the following would be an abnormal finding?

A. Tenderness
B. Pulsations
C. Masses
D. All of the above

Answer 17

D. All of the above

Question 18

When percussing the thorax, which of the following would be a normal finding?

A. Dullness over the lung fields
B. Resonance over the lung fields
C. Dullness over the ribs, heart, and diaphragm
D. Both B and C

Answer 18

D. Both B and C

Question 19

Normal breath sounds include:

A. Vesicular sounds
B. Rhonchi
C. Wheezes
D. Crackles

Answer 19

A. Vesicular sounds

Question 20

When auscultating the lungs, it is important to:

A. Compare each side bilaterally.
B. Note abnormal sounds.
C. Ask the patient to take slow, deep breaths.
D. All of the above.

Answer 20

D. All of the above.

Question 21

While the preoperative nurse is performing the preoperative assessment, a patient admits spending a lot of time sitting after retirement. This predisposes the patient to which factor?

A. Depression and anxiety
B. Noncompliance with discharge instructions
C. Poor postoperative wound healing
D. Development of pressure injuries

Answer 21

D. Development of pressure injuries

Question 22

Which statement is true regarding the formation of PIs?

A. A PI develops when localized damage to the skin and underlying soft tissue occurs.
B. PIs to the skin or underlying soft tissue usually result from intermittent pressure.
C. Positioning during an operative or invasive procedure decreases the patient’s risk for skin breakdown and PI development.
D. Patients undergoing an operative or invasive procedure are at a low risk for developing PIs.

Answer 22

A. A PI develops when localized damage to the skin and underlying soft tissue occurs.

Question 23

Which intrinsic factor increases the patient’s risk of developing a PI during an operative or invasive procedure?

A. Pressure, friction, and shear forces
B. Nutritional status, low hemoglobin level, and BMI of less than 18
C. Moisture, heat, and use of cardiopulmonary bypass
D. Age younger than 60 years, nutritional status, and high hemoglobin level

Answer 23

B. Nutritional status, low hemoglobin level, and BMI of less than 18

Question 24

A 40-year-old biological male patient is scheduled for a procedure that is anticipated to last 3 hours or more. The patient is in the left lateral position. The patient’s history includes diabetes and decreased mobility. In addition to the patient’s history, why is there an increased risk for PIs?

A. The patient’s age
B. The patient’s biological sex
C. The procedure type
D. The procedure length

Answer 24

D. The procedure length

Question 25

During a preoperative patient assessment, which precaution should the unscrubbed perioperative team member use to prevent a high-risk patient from developing a medical device–related PI?

A. Place multiple blankets between the patient and support surface.
B. Perform a preoperative patient skin assessment.
C. Place a barrier sleeve underneath the BP cuff.
D. Place a folded sheet under the patient’s forehead when the patient is in the prone position.

Answer 25

C. Place a barrier sleeve underneath the BP cuff.

Question 26

The unscrubbed perioperative team member could not find any gel rolls or positioning devices for a patient that was going to be in the prone position and used rolled towels, blankets, and sheets instead. In addition to an increased risk of a PI, what other injury is the patient at increased risk to develop?

A. Burn
B. None
C. Shear
D. Friction

Answer 26

D. Friction

Question 27

The unscrubbed perioperative team member is gathering the perioperative team to help perform a lateral transfer of a patient from the stretcher to the OR bed. Which item is an extrinsic factor that can prevent PI development?

A. Using an adequate number of perioperative team members required for the lateral transfer
B. Repositioning the patient after the lateral transfer
C. Lifting the patient’s heels during the lateral transfer
D. Verifying that the perioperative team members are ready for the transfer with a countdown

Answer 27

C. Lifting the patient’s heels during the lateral transfer

Question 28

What are the vulnerable areas for increased risk of PI when a patient is positioned in the prone position?

A. Forehead, eyes, ears, chin, breasts, and toes
B. Occiput, hips, sacrum, coccyx, and heels
C. Occiput, elbows, lumbar area, sacrum, and coccyx
D. Dependent side of face and ear, dependent axilla, and dependent hip

Answer 28

A. Forehead, eyes, ears, chin, breasts, and toes

Question 29

Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?

A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment.
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, efficient manner.

Answer 29

B. Use appropriate personal protective equipment.

Question 30

The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?

A. Necrotic tissue
B. Presence of slough
C. Granulation tissue
D. Development of an infection

Answer 30

C. Granulation tissue

Question 31

Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?

A. Height and weight
B. Length and width
C. Length and depth
D. Width and depth

Answer 31

B. Length and width

Question 32

How would the nurse safely apply an enzyme debridement ointment?

A. Daub ointment on dead tissue at the wound edges.
B. Put ointment on a tongue blade, and gently spread it on the center of the wound.
C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
D. Apply a gauze dressing to ensure contact with the ointment.

Answer 32

C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.

Question 33

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient?

A. Reposition the patient at least every 2 hours.
B. Assess the patient’s bony prominences every shift.
C. Educate the family about the importance of healthy skin.
D. Assist the patient in the selection of high-protein foods.

Answer 33

A. Reposition the patient at least every 2 hours.

Question 34

Physical examination [4 parts]

Answer 34

Inspection
Auscultation
Palpation
Percussion

Question 35

Assessing signs & symptoms

Variables:
-Onset
-Location
-Duration
-Characteristics
-Aggravating factors
-Relief factors
-Treatment

Answer 35

Variables:
-Onset
-Location
-Duration
-Characteristics
-Aggravating factors
-Relief factors
-Treatment

Question 36

_____________ Data- Health history Qs

Previous history of skin disease?
Change in mole?
Change in pigmentation?
Excessive dryness/moisture?
Pruiritus
Excessive bruising
Rash or lesion
Medications
Hair loss
Change in nails
Environmental hazards
Self-care behaviors

Answer 36

Subjective

Question 37

__________ Data- Skin

Inspect and palpate

Color
-General pigmentation
-Widespread color change
–Pallor [pale]
–Erythema [red]
–Cyanosis [blue]
–Jaundice [yellow]

Answer 37

Objective

Question 38

Cyanosis is usually due to low ___________

Answer 38

perfusion

Question 39

Erytheme can happen anywhere, typically due to:

Answer 39

inflammation, may be associated with infection

Question 40

____________ data

Temperature
-Hypothermia
-Hyperthermia

Moisure
-Diaphoresis [hot, sweaty]
-Dehydration [lack of fluid]

Answer 40

Objective data

Temperature
-Hypothermia
-Hyperthermia

Moisure
-Diaphoresis [hot, sweaty]
-Dehydration [lack of fluid]

Question 41

_____________ data- Skin

-Texture
-Thickness
-Edema
-Mobility & turgor
-Vascularity or bruising
-Lesions
◦ Color
◦ Elevation
◦ Pattern or shape
◦ Size
◦ Location and distribution on body
◦ Exudate

Answer 41

Objective data- Skin

Texture
Thickness
Edema
Mobility & turgor
Vascularity or bruising
-Lesions
◦ Color
◦ Elevation
◦ Pattern or shape
◦ Size
◦ Location and distribution on body
◦ Exudate

Question 42

Edema

1-4 pitting scale

Answer 42

Question 43

Objective data- hair

Inspect and palpate
◦ Color
◦ Texture
◦ Distribution
◦ Lesions

Answer 43

Inspect and palpate
◦ Color
◦ Texture
◦ Distribution
◦ Lesions

Question 44

Objective data- nails

Inspect and palpate
◦ Shape and contour
> Profile sign – Clubbing
◦ Consistency
◦ Color
> Capillary refill

Answer 44

Inspect and palpate
◦ Shape and contour
> Profile sign – Clubbing
◦ Consistency
◦ Color
> Capillary refill

Question 45

Identify this

Answer 45

Clubbing

Question 46

Teach skin self-examination, using the ABCDE rule

Answer 46

◦ A—asymmetry
◦ B—border
◦ C—color
◦ D—diameter
◦ E—elevation and enlargement

Question 47

Lesions caused by trauma/abuse: pattern injury; what to look out for?

Answer 47

Question 48

_____________ - pooling of blood under the skin, usually raised

Answer 48

Hematoma

Question 49

Lymphatics

• Preauricular
• Posterior auricular (mastoid)
• Occipital
• Submental
• Submandibular

Answer 49

Question 50

____________ data- Health history Qs

-Headache
-Head injury
- Dizziness
-Neck pain or limitation of motion
- Lumps or swelling
- History of head or neck surgery

Answer 50

Subjective

Question 51

___________ data- head

Inspect and palpate the skull
- Size and shape
- Temporal area

Inspect the face
- Facial structures

Answer 51

Objective

Question 52

__________ data- neck

Inspect and palpate
-Symmetry
-Range of motion
-Lymph nodes
-Trachea
-Thyroid gland
◦ Posterior approach
◦ Anterior approach
◦ Auscultate

Answer 52

Objective

Question 53

Syncope (SINK-a-pee) is another word for for: _______________________

Answer 53

fainting or passing out.

Question 54

You will first see changes in skin color where?

Answer 54

Periphery- hands/feet

Question 55

Perform screening neurologic examination on ______ persons with no significant findings from history

Perform complete neurologic examination on persons with _____________ concerns, e.g., headache, weakness, loss of coordination, or who have shown signs of neurologic dysfunction

Perform neurologic recheck examination on persons with demonstrated ____________ ____________ who require periodic assessments, e.g., hospitalized persons or those in extended care or if status changes

Answer 55

Perform screening neurologic examination on well persons with no significant findings from history

Perform complete neurologic examination on persons with neurologic concerns, e.g., headache, weakness, loss of coordination, or who have shown signs of neurologic dysfunction

Perform neurologic recheck examination on persons with demonstrated neurologic deficits who require periodic assessments, e.g., hospitalized persons or those in extended care or if status changes

Question 56

Complete neuro exam includes:

_________ Status
________ Nerves
_________ System
___________ Function
___________

Answer 56

Mental Status
Cranial Nerves
Motor System
Sensory Function
Reflexes

Question 57

Neuro check- steps 1,2,3

1) Assess _______________________________ ◦ Patient alert, opens eyes spontaneously, answers to person, place or time ◦ Abnormal: stuporous (lack of mental function), unresponsive and
comatose

2) Assessment of _____________
◦ PERRL: pupils equal (involuntary movements), round, reactive to light
◦ Abnormal: nystagmus, constricted, dilated, unequal pupils

3) ______________ of body
◦ Smooth and symmetric
◦ Abnormal: abnormal flexion and extension, hemiplegia (paralysis) vs.
hemiparesis (weakness)

Answer 57

1) Assess Level of Consciousness (LOC) ◦ Patient alert, opens eyes spontaneously, answers to person, place or time ◦ Abnormal: stuporous (lack of mental function), unresponsive and
comatose

2) Assessment of pupils
◦ PERRL: pupils equal (involuntary movements), round, reactive to light
◦ Abnormal: nystagmus, constricted, dilated, unequal pupils

3) Movements of body
◦ Smooth and symmetric
◦ Abnormal: abnormal flexion and extension, hemiplegia (paralysis) vs.
hemiparesis (weakness)

Question 58

Neuro check- steps 4, 5, 6

4) ___________ Nerves

5) ____________ Bulk
◦ Relaxed muscles, resistance, grips equal
◦ Abnormal: no resistance, floppy, spasticity, rigidity

6) __________
◦ Smooth without swaying
◦ Abnormal: scissoring gait, Parkinson’s gait, dystonia
◦ Test: Romberg – standing position with eyes closed

Answer 58

4) Cranial Nerves

5) Muscle Bulk
◦ Relaxed muscles, resistance, grips equal
◦ Abnormal: no resistance, floppy, spasticity, rigidity

6) Walking
◦ Smooth without swaying
◦ Abnormal: scissoring gait, Parkinson’s gait, dystonia
◦ Test: Romberg – standing position with eyes closed

Question 59

Physical exam materials for a neuro check:

◦ Penlight
◦ Tongue blade
◦ Cotton swab
◦ Cotton ball
◦ Tuning fork
◦ Percussion hammer
◦ Occasionally need: familiar aromatic substance

Answer 59

◦ Penlight
◦ Tongue blade
◦ Cotton swab
◦ Cotton ball
◦ Tuning fork
◦ Percussion hammer
◦ Occasionally need: familiar aromatic substance

Question 60

Cranial nerves mnemonic

Know all of the cranial nerves for head to toe assessment

Answer 60

On Old Olympus’ Towering Tops, A Finn And German Viewed Some Hops

or

Ooh, Ooh, Ooh To Touch And Feel Very Good Velvet. A Heaven!

Question 61

I Olfactory – test one __________ at a time

Answer 61

nostril

Question 62

II Optic – visual _________, visual ________, fundoscopic exam

Answer 62

visual acuity, visual fields, fundoscopic exam

Question 63

III Occulomotor – _________ size, shape and reaction to light (direct and consensual) and
accommodation PERRLA – pupils equal, round, reactive to light and accomodation

Answer 63

pupil size, shape and reaction to light (direct and consensual) and
accommodation PERRLA – pupils equal, round, reactive to light and accomodation

Question 64

IV Trochlear – downward inward movement of _______

Answer 64

eye

Question 65

V Trigeminal Motor – temporal and masseter muscles, ______ movement
Sensory – opthalmic, maxillary and mandibular

Answer 65

temporal and masseter muscles, jaw movement
Sensory – opthalmic, maxillary and mandibular

Question 66

VI Abducens – lateral deviation of the ______

Answer 66

eye

Question 67

VII Facial
Sensory – _______
Motor – facial ____________, expression, closing eyes

Answer 67

Sensory – taste
Motor – facial movement, expression, closing eyes

Question 68

VIII Acoustic – _________, air and bone conduction, _____________

Answer 68

hearing, air and bone conduction, balance

Question 69

IX Glossopharyngeal
Motor – pharynx
Sensory – _______ - posterior tongue

Answer 69

Motor – pharynx
Sensory – taste - posterior tongue

Question 70

X Vagus – pharynx, larynx – say _____

Answer 70

“ah”

Question 71

XI Spinal accessory – sternocleidomastoid and ___________

Answer 71

sternocleidomastoid and trapezius

Question 72

XII Hypoglossal - _________

Answer 72

tongue

Question 73

Cerebellar function - __________ tests
◦ Gait
◦ Romberg Test

Answer 73

balance

Question 74

Coordination and skilled movements
◦ Rapid Alternating _____________ (RAM)
◦ Finger-to-Finger/______Test

Answer 74

◦ Rapid Alternating Movements (RAM)
◦ Finger-to-Finger/Nose Test

Question 75

Discrimination

Stereognosis – identify a ___________

Graphesthesia – identify a __________

Two-Point Discrimination – distance at which two points are _______

Answer 75

Stereognosis – identify a familiar object

Graphesthesia – identify a number

Two-Point Discrimination – distance at which two points are felt

Question 76

Four types of reflexes:

______ tendon reflexes (myotatic), e.g., knee jerk

___________ , e.g., corneal reflex, abdominal reflex

__________ , e.g., pupillary response to light

___________ (abnormal), e.g., Babinski’s reflex or extensor plantar reflex - Pediatrics

Answer 76

Deep tendon reflexes (myotatic), e.g., knee jerk

Superficial, e.g., corneal reflex, abdominal reflex

Visceral, e.g., pupillary response to light

Pathologic (abnormal), e.g., Babinski’s reflex or extensor plantar reflex - Pediatrics

Question 77

Always compare reflexes _______________

Answer 77

bilaterally

Question 78

Reflex grading system: ?

Answer 78

0-4

0- no response
4- hyperactive

4+ Very brisk / Hyperactive
◦ 3+ More brisk than expected
◦ 2+ Average / expected (normal)
◦ 1+ Sluggish or diminished response
◦ 0 No response

Question 79

Glasgow coma scale

Most common scoring system used to describe the _______________________ in a person following a ___________________

Basically, it is used to help gauge the __________ of an acute brain injury.

Answer 79

Most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury.

Basically, it is used to help gauge the severity of an acute brain injury.

Question 80

Musculoskeletal system - subjective data- health history Qs

__________
◦ Pain
◦ Stiffness
◦ Swelling, heat, and redness

__________
◦ Pain (cramps)
◦ Weakness

_________
◦ Pain
◦ Deformity
◦ Trauma (fractures, sprains, dislocations)

Answer 80

Joints
◦ Pain
◦ Stiffness
◦ Swelling, heat, and redness

Muscles
◦ Pain (cramps)
◦ Weakness

Bones
◦ Pain
◦ Deformity
◦ Trauma (fractures, sprains, dislocations)

Question 81

Musculoskeletal system - subjective data- health history Qs

Functional assessment ________
◦ Bathing
◦ Toileting
◦ Dressing/Grooming
◦ Eating
◦ Mobility
◦ Communicating

Self-care behaviors

Answer 81

Functional assessment (ADL’s)
◦ Bathing
◦ Toileting
◦ Dressing/Grooming
◦ Eating
◦ Mobility
◦ Communicating

Self-care behaviors

Question 82

Objective data- musculoskeletal system

Order of the examination

◦ ____________
Size and contour of joint
Skin and tissues over joint – color, swelling, deformities

◦ ___________
Skin temperature
Muscles, bony articulations, area of joint capsule

◦ ________________
Active
Passive

◦ ____________ testing
Apply opposing force
Grading muscle strength

Answer 82

◦ Inspection
Size and contour of joint
Skin and tissues over joint – color, swelling, deformities

◦ Palpation
Skin temperature
Muscles, bony articulations, area of joint capsule

◦ Range of motion
Active
Passive

◦ Muscle testing
Apply opposing force
Grading muscle strength

Question 83

Range of motion (ROM)

____________ movement that is possible for that _________

Determined by genetics, disease, amt of physical activity

Answer 83

Maximum movement that is possible for that joint

Determined by genetics, disease, amt of physical activity

Question 84

Flexion vs extension

Answer 84

Question 85

abduction vs adduction

Answer 85

Question 86

circumduction

Answer 86

Question 87

Elevation vs depression

Answer 87

Question 88

Protraction vs retraction

Answer 88

Question 89

eversion vs inversion

Answer 89

Question 90

Nevi are:

Answer 90

moles

Question 91

To thoroughly inspect nevi [moles], the nurse should look for:

Size (diameter <6 mm)
Number—The healthy adult may have as many as 40 nevi throughout the body.
Color/degree of pigmentation
Location—Nevi can be found on all body surfaces but are rarely found on the scalp, breasts, and buttocks.
Shape
Surface
Symmetry
Border (regular vs. irregular)

Answer 91

Size (diameter <6 mm)
Number—The healthy adult may have as many as 40 nevi throughout the body.
Color/degree of pigmentation
Location—Nevi can be found on all body surfaces but are rarely found on the scalp, breasts, and buttocks.
Shape
Surface
Symmetry
Border (regular vs. irregular)

Question 91

The healthy adult may have as many as ____ nevi throughout the body.

Answer 91

10 - 40

Question 92

Which areas of the body rarely have normal nevi?

Scalp

Breasts

Buttocks

Torso

Face

Answer 92

Scalp

Breasts

Buttocks

Question 93

the nurse will use the thumb and forefinger to assess skin ____1____, which can indicate a patient’s ______2_______ status.

Answer 93

1- turgor

2- hydration

Question 94

Macules: _____ lesion, less than 1 cm diameter [freckles/ petechiae]

Answer 94

flat

Question 95

Papules: ____________ , solid demarcated lesion less than 1cm [warts/ some moles]

Answer 95

elevated

Question 96

___________ : elevated lesions, under 1 cm, filled with serous fluid [chickenpox/shingles]

Answer 96

Vesicles

Question 97

Bullae: _________ greater than 1 cm [blister]

Answer 97

Vesicle

Question 98

___________ : elevated lesions under 1 cm, filled with pus [impetigo/acne]

Answer 98

Postules

Question 99

__________ : elevated, firm, coarse/scaly lesions greater than 1 cm [psoriasis]

Answer 99

Plaques

Question 100

___________ - excess hair most often noticeable around the mouth and chin

[high androgen in women]

Answer 100

Hirsutism

Question 101

Lack of hair on lower extremities is an abnormal finding, and can be associated with poor:

Answer 101

perfusion

Question 102

Which elements would the nurse assess to evaluate cranial nerve XII?

Answer 102

Speech sounds

Question 103

Which elements should be assessed to evaluate the glossopharyngeal nerve (CN IX)?

Answer 103

Gag reflex
Swallowing

Question 104

Which olfactory element would the nurse evaluate as part of the assessment of the olfactory nerve (CN I)?

Answer 104

Odor identification

Question 105

The nurse would inspect the face for which elements when assessing the trigeminal nerve (CN V)?

Select all that apply.

Color

Atrophy

Tremors

Fasciculation

Reaction to touch

Answer 105

Atrophy

Tremors

Fasciculation

Question 106

The nurse would assess which elements of the jaw during assessment of trigeminal nerve (CN V)?

Answer 106

Tone
Strength

Question 107

Which aspect of the foot should the nurse assess to evaluate the plantar reflex?

Answer 107

Heel > ball

Question 108

Equilibrium is evaluated with the ___________ test.

Answer 108

Romberg

Question 109

To assess _______ :

Observe as the patient walks 10 to 20 feet, turns, and returns to the starting point.
Ask the patient to walk a straight line in heel-to-toe fashion; this decreases the base of support and accentuates any problem with coordination. Test for balance by asking the patient to walk on the toes, then on the heels for a few steps.

Answer 109

gait

Question 110

CN I is responsible for _______.

CN II is responsible for __________.

Answer 110

CN I is responsible for smell
CN II is responsible for vision.

Question 111

Full movement of the eyes is controlled by the integrated function of cranial nerves______________________

Included in these nerves are the oculomotor, trochlear, and abducens nerves, and the six extraocular muscles.

Answer 111

III, IV, and VI.

Question 112

CN V governs facial sensation and _________.

CN VII controls facial muscles and sense of _______.

Answer 112

CN V governs facial sensation and chewing.

CN VII controls facial muscles and sense of taste.

Question 113

CN VIII enables ___________ .

Answer 113

hearing

Question 114

CN IX controls _____________ movements.

CN X governs swallowing and _________.

Answer 114

CN IX controls swallowing movements.

CN X governs swallowing and speech.

Question 115

CN XI is responsible for shoulder and head _____________ .

CN XII controls __________ movement.

Answer 115

CN XI is responsible for shoulder and head movement.

CN XII controls tongue movement.

Question 116

Which cortical sensory function would the nurse assess by drawing a number 8 on the patient’s hand?

Answer 116

Graphesthesia

Graphesthesia, or the ability to identify writing on the skin, is the cortical sensory function assessed by drawing a number 8 on the patient’s hand.

Question 117

Which elements of the pupils should be evaluated as part of the assessment of the cranial nerves of the eyes?

Answer 117

Size
The nurse should evaluate the size of the pupils as part of the assessment of the cranial nerves of the eyes.

Color
The nurse would not evaluate eye color as part of the assessment of the cranial nerves of the eyes.
Correct

Equality
The nurse should evaluate the equality of the pupils as part of the assessment of the cranial nerves of the eyes.

Response to light
The nurse should evaluate the response of the pupils to light as part of the assessment of the cranial nerves of the eyes.

Question 118

When evaluating the vagus nerve (CN X), the nurse should inspect which aspect of the palate and uvula?

Answer 118

Symmetry

When evaluating the vagus nerve (CN X), the nurse should inspect the symmetry of the palate and uvula because the vagus nerve provides motor supply to the pharynx.

Question 119

Which sensory elements should the nurse assess when evaluating the acoustic nerve (CN VIII)?

Answer 119

Hearing
The nurse would assess the patient’s hearing when evaluating the acoustic nerve (CN VIII).

Balance
The nurse would assess the patient’s balance when evaluating the acoustic nerve (CN VIII).

Question 120

The nurse should use which tests to assess the accuracy of the patient’s movements?

Answer 120

Finger-to-nose test
The nurse should evaluate the ability of the patient to touch a finger to the nose to assess the accuracy of the patient’s movements.
Correct

Finger-to-finger test
The nurse should evaluate the ability of the patient to touch a finger to another finger to assess the accuracy of the patient’s movements.

Heel-to-shin test
The nurse should evaluate the ability of the patient to touch the heel to the shin to assess the accuracy of the patient’s movements.

Question 121

Abnormal findings: Primary VS Secondary skin lesions

Primary
─ Macule
─ Papule
─ Patch
─ Plaque
─ Nodule
─ Wheal
─ Tumor
─ Urticaria (hives)
─ Vesicle
─ Cyst
─ Bulla
─ Pustule

Secondary
─ Crust
─ Scale
─ Fissure
─ Erosion
─ Ulcer
─ Excoriation
─ Scar
─ Atrophic scar
─ Lichenification
─ Keloid

Answer 121

Primary
─ Macule
─ Papule
─ Patch
─ Plaque
─ Nodule
─ Wheal
─ Tumor
─ Urticaria (hives)
─ Vesicle
─ Cyst
─ Bulla
─ Pustule

Secondary
─ Crust
─ Scale
─ Fissure
─ Erosion
─ Ulcer
─ Excoriation
─ Scar
─ Atrophic scar
─ Lichenification
─ Keloid

Question 122

________ – involuntary muscle contract/relax

Answer 122

Clonus

Question 123

Grading muscle strength

Answer 123

5 Full ROM/full resistance 100% Normal
4 Full ROM/some resistance 75% Good
3 Full ROM 50% Fair
2 Full ROM/passive-w/ support 25% Poor
1 Slight contraction 10% Trace
0 No contraction 0% Zero

Question 124

While assessing a client’s vascular system, the nurse finds a diminished and barely papable pulse strength. Which documentation would the nurse utilize in this situation?

1+

2+

3+

4+

Answer 124

1+

A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.

Question 125

When assessing a client who had a thyroidectomy yesterday, which cue would the nurse associate with an initial sign of hypocalcemia?

Headache

Pallor

Paresthesias

Blurred vision

Answer 125

Paresthesias [Tingling or prickling, “pins-and-needles” sensation]

Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

Question 126

Which information, obtained during a client’s health history, would the nurse classify as biographical information? Select all that apply. One, some, or all responses may be correct.

Symptoms

Client’s age

Family structure

Type of insurance

Occupation status

Answer 126

Client’s age

Type of Insurance

Occupation status

Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client’s age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

Question 127

The nurse just arrived on the unit for his shift. Which action would the nurse take first to collect an initial set of data about the clients assigned to the nurse’s care?

Meet the clients’ family.

Read the clients’ medical reports.

Participate in the bedside rounds.

Visit the clients and introduce self.

Answer 127

Participate in the bedside rounds.

The nurse would participate in bedside rounds with the health care team from the previous shift. The nurse who is completing care for one shift prepares the change-of-shift report to communicate client details to the nurse on the next shift. These bedside rounds provide patient-centered care, because the nurse shares information about the client’s condition, status of problems, and treatment plan for the next shift. The nurse can meet the client’s family after obtaining firsthand information from the nurse completing the shift. The nurses review the client’s medical reports and discuss treatment plans for the next shift after completing bedside rounds. The nurse may meet the client during bedside rounds or after obtaining the handover report.

Question 128

Which step would the nurse take first when preparing a concept map for as assigned client?

Assess the client and gather information.

Arrange cues into clusters that form patterns.

Identify patterns reflecting the client’s problem.

Identify specific nursing diagnoses for the client.

Answer 128

Arrange cues into clusters that form patterns.

A concept map is a visual representation of the connection between the client’s many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client’s problem. The concept map helps the nurse obtain a holistic view of the client’s needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided

Question 129

For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes?

Skeletal and nervous

Circulatory and urinary

Respiratory and urinary

Muscular and endocrine

Answer 129

Respiratory and urinary

Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps adjust the body’s pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

Question 130

When providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease?

Pulse rate

Tissue turgor

Specific gravity

Body temperature

Answer 130

Tissue turgor

Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body’s cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.

Question 131

Which nurse’s action would help set the stage for a client-centered interview? Select all that apply. One, some, or all responses may be correct.

Close the door after entering the room.

Greet the client using his or her last name.

Open the curtains to allow plenty of light in the room.

Introduce oneself with a smile and explain the reason for the visit.

Obtain an authorization from the client after the interview.

Answer 131

Close the door after entering the room.

Greet the client using his or her last name.

Introduce oneself with a smile and explain the reason for the visit.

Question 132

The nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. In which way would the nurse document the edema?

1+

2+

3+

4+

Answer 132

4+

Question 133

Which Korotkoff sound represents the diastolic pressure for children?

First

Second

Fourth

Fifth

Answer 133

Fourth

The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.

Question 134

Which factor would cause the nurse to identify an illness as chronic? Select all that apply. One, some, or all responses may be correct.

The illness is reversible and often severe.

The illness persists for longer than 6 months.

The client may develop a life-threatening relapse.

The symptoms are intense and appear abruptly.

The illness affects the functioning of one or more systems.
Confident

Answer 134

The illness persists for longer than 6 months.

The client may develop a life-threatening relapse.

The illness affects the functioning of one or more systems.

Question 135

Which nursing intervention would the nurse use to encourage the client to verbalize their personal health problem?

The nurse takes down notes while the client is talking.

The nurse leans forward attentively during the discussion.

The nurse refrains from pausing enough after each question.

The nurse asks questions that can be answered as “yes” or “no.”

Answer 135

The nurse leans forward attentively during the discussion.

Question 136

For an older adult client, admitted to the health care facility following a stroke, which action would the nurse take when the client’s cousin asks to see the client’s health record?

Confirm the client’s relationship first.

Ask the client’s primary health care provider.

Inform the nurse manager and show the records.

Explain medical health records are confidential.

Answer 136

Explain medical health records are confidential.

Question 137

For a client who arrived at the health care facility for an appointment, which nurse’s action would be beneficial during the assessment interview?

Ask about the client’s current concerns

Ensure the interview follows a strict agenda

Ask questions that promote short responses by the client

Tell the client what they should expect from the visit

Answer 137

Ask about the client’s current concerns

Question 138

Which nurse’s statement indicates the client’s interview is coming to a close?

“I have just one more question for you.”

“I hope you are comfortable and not in pain.”

“I would like to spend some time to understand your concerns.”

“I assure you that information I gather now will be confidential.”

Answer 138

“I have just one more question for you.”

Question 139

For a client suspected of having a prostate disorder, which client position would facilitate a rectal examination by the registered nurse (RN)?

Left lateral recumbent position

Prone position

Dorsal recumbent position

Lateral recumbent position

Answer 139

Left lateral recumbent position

Question 140

Arrange the steps of the bimanual deep palpation technique in sequence.

Apply pressure to the sensing hand
Place the sensing hand on the skin
Depress the area to be examined to 2 inches
Place the active hand on the sensing hand
Relax sensing hand

Answer 140

During a deep palpation, the area under the examination is depressed to 2 inches using one or both hands. When both the hands are used for palpation, the sensing hand is relaxed and placed over the client’s skin. Then the active hand is placed over the sensing hand, and pressure is applied on the sensing hand.

Question 141

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the nurse’s hand would the nurse use to perform this assessment?

Fingertips

Pads of fingertips

Ulnar surface of hand

Palmer surface of finger pads

Answer 141

Fingertips

Question 142

The nurse documents data that was gathered during an assessment in a client’s medical record. Which action would the nurse take to ensure that the data is meaningful to other health care providers?

Record subjective information in own words.

Form judgments through written communication.

Record objective information using accurate terminology.

Compare data from the physical examination with client behavior.

Answer 142

Record objective information using accurate terminology.

Question 143

When would the nurse observe a client to assess their level of functioning? Select all that apply. One, some, or all responses may be correct.

During mealtime

When talking about pain

When preparing medication

During the assessment interview

When administering insulin injections

Answer 143

During mealtime

When preparing medication

When administering insulin injections

Question 144

Which feature distinguishes nursing diagnoses from medical diagnoses? Select all that apply. One, some, or all responses may be correct.

Nursing diagnoses involve the client when possible.

Nursing diagnoses are based on results of diagnostic tests and procedures.

Nursing diagnoses are the identification of a disease condition in the client.

Nursing diagnoses involve the sorting of health problems within the nursing domain.

Nursing diagnoses involve clinical judgment about the client’s response to health problems.

Answer 144

Nursing diagnoses involve the client when possible.

Nursing diagnoses involve the sorting of health problems within the nursing domain.

Nursing diagnoses involve clinical judgment about the client’s response to health problems.

Question 145

The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client’s temperature. Which action is the nurse taking?

Validation

Assessment

Interpretation

Documentation

Answer 145

Validation

The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data; it involves clarifying vague or unclear data. Assessment is the first step of the nursing process; it involves collecting information from the client and secondary sources. During interpretation, the nurse recognizes that further observations are needed to clarify information. Data documentation is the last part of a complete assessment. The nurse must document facts in a timely, thorough, and accurate manner to prevent information from getting lost.

Question 146

When conducting a health assessment for a school-age child who is a new client to the pediatric practice, which question would the nurse ask the child and parents related to growth? Select all that apply. One, some, or all responses may be correct.

“Which grade are you currently attending?”

“At which age did your child cut their first tooth?”

“Do you have a best friend at your new school?”

“What was your child’s approximate length at 1 year of age?”

“What was your child’s approximate weight at 6 months, and 1, 2, and 5 years of age?”

Answer 146

“At which age did your child cut their first tooth?”

“What was your child’s approximate length at 1 year of age?”

“What was your child’s approximate weight at 6 months, and 1, 2, and 5 years of age?”

Question 147

A client with a family history of diabetes mellitus has been following a diet regimen recommended by the dietitian and walking for 45 minutes daily for the past 8 months. Based on the transtheoretical model of health behavior change, which stage would the nurse document for this client?

Action

Preparation

Maintenance

Contemplation

Answer 147

Maintenance

The client is in the maintenance stage of human behavior change. During this stage, the client has managed to incorporate the changes into the lifestyle. This stage begins 6 months after the action has started and continues indefinitely. The action stage lasts for 6 months from the time the client has incorporated the changes into the lifestyle. During the preparation stage, the client begins to realize that the advantages of the change outweigh the disadvantages. The client starts making small changes in preparation for major changes the following month. During the contemplation stage, the client is still considering whether to incorporate changes in the next 6 months.

Question 148

A client reports right ear hearing loss. When performing a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results?

Normal hearing

Mixed hearing loss

Conduction hearing loss

Sensorineural hearing loss

Answer 148

Conduction hearing loss

During a Weber test, conduction hearing loss often causes the tuning fork to be heard better and more clearly in the impaired ear. People with sensorineural hearing loss will hear the sound better in the normal (in this case the left) ear. Mixed hearing loss is a combination of both conduction and sensorineural hearing loss and would not result in the findings observed with the Weber test. The client does not have normal hearing.

Question 149

When an African American client with renal failure reports the illness is a punishment for sins, which cultural health belief is the client communicating?

Yin/Yang balance

Biomedical belief

Determinism belief

Magicoreligious belief

Answer 149

Magicoreligious belief

An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe illness is a punishment for sins. The yin/yang belief system does not consider illness as a punishment. The biomedical belief system maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes. The belief of determinism focuses on outcomes that are externally preordained and cannot be changed.

Question 150

While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma?

Blurred central vision

Increased opacity of the lens

Elevated intraocular pressure

Changes in retinal blood vessels

Answer 150

Elevated intraocular pressure

In glaucoma, there is an obstruction of the outflow of aqueous humor due to intraocular structural damage, which may result from elevated intraocular pressure. Blurred central vision is seen in macular degeneration. Increased opacity of the lens may be seen in cataracts. Retinopathy may result from the changes in retinal blood vessels.

Question 151

The nurse, providing care for a client who underwent cardiac catheterization, found the client’s skin was cool, tender to touch, with edema of 15.2 cm (1–6 inches) at the site of catheterization. Which condition would the nurse suspect?

Phlebitis

Infection

Infiltration

Circulatory overload

Answer 151

Infiltration

The client with blanched skin, edema of 15.2 cm, cool temperature, and pain at the site of catheterization has symptoms of grade 2 infiltration. Phlebitis is an inflammation of the inner layer of the vein. The findings for this include redness, tenderness, pain, and warmth along the course of the vein starting at the access site. If there is infection, there will be findings that include redness, heat, swelling at catheter-skin entry point, and possible purulent drainage. Circulatory overload can occur if intravenous solutions are infused too rapidly or in great amounts.

Question 152

After performing an optical assessment on a client, a primary health care provider notices impaired near vision. Which other finding would confirm the client’s diagnosis as presbyopia?

Loss of elasticity of the lens

Increased opacity of the lens

Elevated intraocular pressure

Noninflammatory changes in eyes

Answer 152

Loss of elasticity of the lens

Presbyopia is defined as impaired near vision caused by a loss of elasticity of the lens. This condition is reported in middle-aged and older adults. Increased opacity of the lens is seen in cataracts. Elevated intraocular pressure is associated with glaucoma. Retinopathy causes noninflammatory eye changes.

Question 153

Which skin condition would the nurse associate with a client whose skin pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation?

Pallor

Vitiligo

Cyanosis

Erythema

Answer 153

Erythema

Erythema occurs due to an increased visibility of oxyhemoglobin, which is caused by increased blood flow. Pallor is caused by a reduced amount of oxyhemoglobin or a reduced visibility of oxyhemoglobin. Vitiligo is a pigmentation disorder caused by autoimmune diseases. Cyanosis is a bluish discoloration of the skin around the lips; this occurs due to an increased amount of deoxygenated hemoglobin in the blood.

Question 154

After an eye assessment, the nurse finds that the client’s eyes are not focusing on an object simultaneously and appear crossed. Which potential cause would the nurse associae with this condition?

Loss of elasticity of the lens

Impairment of the extraocular muscles

Obstruction of the aqueous humor outflow

Progressive degeneration of the center of the retina

Answer 154

Impairment of the extraocular muscles

Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.

Question 155

___________ is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles.

Answer 155

Strabismus

Question 156

Of which cranial nerve does the nurse assess the function when asking the client to shrug their shoulders and to turn their head against passive resistance?

Cranial nerve II

Cranial nerve XI

Cranial nerve VI

Cranial nerve VII

Answer 156

Cranial nerve XI

Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders.

Question 157

Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of ______________________

Answer 157

head and shoulders.

Question 158

Which benefit would the nurse associate with using standard, formal, nursing diagnostic statements? Select all that apply. One, some, or all responses may be correct.

Fosters development of nursing knowledge

Allows nurses to communicate with the client

Provides precise definition of the client’s problem

Distinguishes the nurse’s role from that of other care providers

Enables the primary health care provider to deliver effective health care

Answer 158

Fosters development of nursing knowledge

Provides precise definition of the client’s problem

Distinguishes the nurse’s role from that of other care providers

The use of standard formal nursing diagnostic statements fosters the development of nursing knowledge, which is important to be able to assess a client’s specific risk for problems, identify them early, and take preventive action. Nursing diagnostic statements provide precise definitions of the client’s problem. They give the nurses and other members of the health care team a common language for understanding the client’s needs. Nursing is emphasized as an independent practice when the nurse formulates nursing diagnoses and individualized nursing care plans. This distinguishes the nurse’s role from that of other care providers. Nursing diagnostic statements allow nurses to communicate what they do among themselves with other health care professionals and the public. A nursing diagnosis helps the nurse focus on the scope of nursing practice and to deliver effective health care.

Question 159

Which type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once a day?

Sustained

Relapsing

Remittent

Intermittent

Answer 159

Intermittent

An intermittent fever is characterized by fever spikes interspersed with normal temperatures. In this type of fever, the body temperature returns to normal at least once in 24 hours. In the case of sustained fever, there is a constant body temperature greater than 100.4°F (38°C). In relapsing fever, there is an occurrence of periods of febrile episodes with acceptable temperature values. In remittent fever, the body temperature increases and decreases without returning to normal body temperature levels.

Question 160

A registered nurse teaches a new nurse about when a client with high blood pressure would follow up with the primary health care provider. Which statement made by the new nurse indicates effective learning?

“I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year.”

“I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year.”

“I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month.”

“I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month.”

Answer 160

“I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year.”

A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in 2 years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in 2 months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in 1 month. If a client’s BP is greater than 180/110 mm Hg, then the client should be treated immediately or within 1 week.

Question 161

Which condition would the nurse suspect when an older adult has a thin white ring around the margin of her iris?

Cataract

Arcus senilis

Conjunctivitis

Macular degeneration

Answer 161

Arcus senilis

In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris. A cataract is a condition involving increased opacity of the lens that blocks light rays from entering the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is marked by a blurring of central vision caused by progressive degeneration of the center of the retina.

Question 162

While assessing a client, the nurse finds inflammation of the skin at the bases of the client’s nails. Which event or disorder would the nurse associate with the reason behind this condition?

Trauma

Trichinosis

Pulmonary disease

Iron-deficiency anemia

Answer 162

Trauma

Paronychia is an abnormality of the nail bed. The condition is marked by inflammation of the skin at the base of the nail; this condition may be caused by trauma or a local infection. Trichinosis is associated with red or brown linear streaks in the nail bed. Pulmonary diseases can cause changes in the angle between nail and nail base, which is a phenomenon known as clubbing. Koilonychia, a concave curvature of the nails, may occur as a result of iron-deficiency anemia.

Question 163

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Pregnancy

Inactivity

Aerobic exercise

Tight clothing

Answer 163

Inactivity

Question 164

A client in the second trimester of pregnancy arrives at the clinic for a general health checkup, including a pelvic examination. For which position would the nurse prepare the client?

Left lateral recumbent position

Supine position

Lithotomy position

Dorsal recumbent position

Answer 164

Lithotomy position

Question 165

While assessing a client who experienced an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve led to this condition in the client?

Optic nerve

Facial nerve

Abducens nerve

Oculomotor nerve

Answer 165

Abducens nerve

The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs. Damage to this nerve limits lateral movement of the eyeball. Injury to the optic nerve causes changes in visual acuity. Injury to the facial nerve results in loss of facial expressions and loss of taste perception from the anterior third of the tongue. Injury to the oculomotor nerve limits the extraocular movements and pupillary responses.

Question 166

During a survey, the community nurse meets a client who never visited a gynecologist after the birth of a second child. The client reports the client’s mother or sister never had annual gynecologic examinations. Which factor appears to be influencing the client’s health practice?

Spiritual belief

Family practices

Emotional factors

Cultural background

Answer 166

Family practices

Question 167

Which nurse’s action is important for establishing good communication with the client who has impaired hearing?

Speaking at a normal volume

Reducing environmental noise

Obtaining the client’s attention before speaking

Rephrasing rather than repeating if misunderstood

Answer 167

Obtaining the client’s attention before speaking

Question 168

When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize?

Using medical terminology

Proceeding in an unhurried manner

Speaking in a low and moderate voice

Pantomiming words and simple actions while verbalizing them

Answer 168

Using medical terminology

Question 169

A client who does not understand English requires an interpreter. Which action by the nurse may exacerbate health disparities?

The nurse expects the interpreter to act as the client’s advocate.

The nurse expects the interpreter to have a health care background.

The nurse maintains steady eye contact with the client.

The nurse talks only to the interpreter about the client.

Answer 169

The nurse talks only to the interpreter about the client.

Question 170

While preparing to teach a client about self-injection of insulin, which nurse’s action would increase the effectiveness of the teaching session?

Wait until a family member is also present.

Assess the client’s barriers to learning self-injection techniques.

Begin with simple written instructions describing the technique.

Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.

Answer 170

Assess the client’s barriers to learning self-injection techniques.

Question 171

While providing postoperative care for a client, who had surgery to repair a deviated septum, the nurse would monitor for which complication associated with this type of surgery?

Occipital headache

Periorbital crepitus

Expectoration of blood

Changes in vocalization

Answer 171

Expectoration of blood

Question 172

In which sequential order would the nurse assess the visual level of a client?

Direct the client to stand or sit 60 cm away from eye level

Close the opposite eye to superimpose the field of vision

Ask the client to close his or her left or right eye gently and look directly at the nurse’s opposite eye

Ask the client to report when he or she is able to see the finger

Move a finger equidistant between the nurse and the client outside the field of vision

Answer 172

The first step while assessing the visual level of the client is to direct the client to stand or sit 60 cm away at eye level.

Next, the nurse would ask the client to gently close or cover one eye and look at the nurse’s eye directly opposite.

Then, the nurse would also close his or her right eye to superimpose the field of vision.

After this, the nurse would move a finger equidistant between the nurse and the client outside the field of vision.

Finally, the nurse would ask the client to report when he or she is able to see the finger.

Question 173

The palpation of the popliteal pulse is done on the popliteal artery, which is present in the posterior surface of the ________

Answer 173

knee

Question 174

When the defining characteristics of a client’s assessment data apply to more than one diagnosis, which action would the nurse take? Select all that apply. One, some, or all responses may be correct.

Reassess the client.

Reject all diagnoses.

Gather more information.

Identify related factors.

Review all defining characteristics.

Answer 174

Gather more information.

Identify related factors.

Review all defining characteristics.

Question 175

A registered nurse teaches a new employee about precautions taken during a client’s physical examination. Which employee’s statement indicates effective learning? Select all that apply. One, some, or all responses may be correct.

“I would examine the client in noise-free areas.”

“I would use latex gloves during the physical examination.”

“I would perform a physical examination in a cool room.”

“I would leave a combative client alone during a physical examination.”

“I would wear eye shields while examining a client with excessive drainage.”

Answer 175

“I would examine the client in noise-free areas.”
“I would wear eye shields while examining a client with excessive drainage.”

Question 176

Pressure injuries (ulcers): _______________________________ due to unrelieved pressure

Answer 176

breakdown of skin integrity

Question 177

Assessment of skin, hair, and nails would include: __________ and _________

Answer 177

Inspect and Palpate

Question 178

___________ data: skin

• Previous history of skin disease
• Change in mole or skin pigmentation
• Excessive dryness or moisture
• Pruritus
• Excessive bruising, rashes, lesions
• Medications
• Hair loss
• Change in nails
• Environmental or Occupational hazards
• Self-care behaviors

Answer 178

Subjective

Question 179

___________ data: skin

COLOR:
PALLOR, ERYTHEMA,
CYANOSIS, JAUNDICE,
FRECKLES, MOLES

TEMPERATURE:
HYPOTHERMIA,
HYPERTHERMIA

MOISTURE:
DIAPHORESIS,
DEHYDRATION

TEXTURE:
NORMAL/ABNORMAL

THICKNESS:
NORMAL/ABNORMAL

EDEMA:
NORMAL/ABNORMAL

TURGOR:
DEHYDRATION, SKIN
ELASTICITY
VASCULARITY/

BRUISING:
ANGIOMAS, LESIONS,
ABUSE

Answer 179

Objective

Question 180

SIGNS AND SYMPTOMS Mnemonic

Answer 180

OLD CARTS

Onset
Location
Duration

Character
Alleviating
Radiation
Temporal patterns
Symptoms

Question 181

EDEMA

___________ effect – can cover other skin signs like jaundice, cyanosis

Answer 181

Masking

Question 182

________________ DATA: HEAD, FACE, & NECK
* Headaches (unusually frequent or severe)
* Head injury history
* Dizziness
* Neck pain or limited ROM
* Lumps or swelling
* History of head or neck cancers or surgery

Answer 182

SUBJECTIVE

Question 183

LYMPH NODES

FUNCTION: ______________________ AND ENGULF PATHOGENS TO PREVENT HARMFUL SUBSTANCES FROM ________________________________

Answer 183

FILTER THE LYMPH AND ENGULF PATHOGENS TO PREVENT HARMFUL SUBSTANCES FROM ENTERING THE CIRCULATION

Question 184

LYMPH NODES

PALPABLE:

Answer 184

HEAD AND NECK, ARMS, INGUINAL AREA, AND AXILLAE

Question 185

NORMAL LYMPH NODES FEEL: _____________ , DISCRETE, SOFT, AND NONTENDER.

Answer 185

MOVEABLE

Question 186

During an examination, the nurse finds that a patient has excessive dryness of the skin.
The best term to describe this condition is:

A. Xerosis.
B. Pruritus.
C. Alopecia.
D. Seborrhea.

Answer 186

A. Xerosis.

Question 187

Xerosis is the term used to describe skin that is excessively _____

Answer 187

dry.

Question 188

Pruritus refers to _________,

Answer 188

itching

Question 189

alopecia refers to ___________

Answer 189

hair loss

Question 190

seborrhea refers to __________

Answer 190

oily skin.

Question 191

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

A. Color variation
B. Border regularity
C. Symmetry of lesions
D. Diameter of less than 6 mm

Answer 191

A. Color variation

Question 192

Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE:
asymmetry of pigmented lesion, border irregularity, color variation, diameter greater
than ________ , and elevation.

Answer 192

6 mm

Question 193

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?

A. Smooth mucous membranes and lips
B. Dry mucous membranes and cracked lips
C. Pale mucous membranes
D. White patches on the mucous membranes

Answer 193

B. Dry mucous membranes and cracked lips

Question 194

With _____________ , mucous membranes appear dry and the lips look parched and cracked.

Answer 194

dehydration

Question 195

The nurse is aware that the four areas in the body where lymph nodes are accessible are the:

A. Head, breasts, groin, and abdomen.
B. Arms, breasts, inguinal area, and legs.
C. Head and neck, arms, breasts, and axillae.
D. Head and neck, arms, inguinal area, and axillae.

Answer 195

D. Head and neck, arms, inguinal area, and axillae.

Nodes are located throughout the body, but they are accessible to examination only in four
areas: head and neck, arms, inguinal region, and axillae.

Question 196

A patient says that she has recently noticed a lump in the front of her neck below her adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):

A. Is tender.
B. Is mobile and not hard.
C. Disappears when the patient smiles.
D. Is hard and fixed to the surrounding structures.

Answer 196

B. Is mobile and not hard.

Question 197

Painless, rapidly growing nodules may be cancerous, especially the appearance of a single
nodule in a young person.

Cancerous nodules tend to be _______ and fixed to surrounding structures, not ___________.

Answer 197

Painless, rapidly growing nodules may be cancerous, especially the appearance of a single
nodule in a young person.

Cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

Question 198

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:

A. Pallor
B. Coolness
C. Distended veins
D. Prolonged capillary filling time

Answer 198

C. Distended veins

Question 199

Keeping the feet in a dependent position causes venous pooling, resulting in redness,
warmth, and _________________

Answer 199

distended veins.

Question 200

Prolonged elevation would cause _________ and coolness.

Answer 200

pallor

Question 201

Immobilization or prolonged inactivity would cause prolonged ___________________ time.

Answer 201

capillary filling

Question 202

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?

A. Severe obesity
B. Childhood growth spurts
C. Severe dehydration
D. Connective tissue disorders such as scleroderma

Answer 202

C. Severe dehydration

Question 203

Decreased skin _________ is associated with severe dehydration or extreme weight loss.

Answer 203

turgor

Question 204

____________ DATA: NEURO
* Headaches
* Head injury
* Dizziness or vertigo
* Seizures
* Tremors
* Weakness
* Incoordination
* Numbness or tingling
* Difficulty swallowing
* Difficulty speaking
* Significant history
* Environmental/Occupational hazards

Answer 204

SUBJECTIVE

Question 205

NEURAL CHECKS

SCREENING NEUROLOGIC EXAMINATION –______ PEOPLE WITH NO HISTORY

COMPLETE NEUROLOGIC EXAMINATION – NEUROLOGIC CONCERNS/NEUROLOGIC
_______________

NEUROLOGIC RECHECK – NEUROLOGIC ____________ AND NEED PERIODIC SCREENING

TOOLS:
* PENLIGHT
* TONGUE BLADE
* COTTON SWAB AND BALL
* TUNING FORK
* PERCUSSION HAMMER

Answer 205

SCREENING NEUROLOGIC EXAMINATION –WELL PEOPLE WITH NO HISTORY

COMPLETE NEUROLOGIC EXAMINATION – NEUROLOGIC CONCERNS/NEUROLOGIC
DYSFUNCTION

NEUROLOGIC RECHECK – NEUROLOGIC DEFICITS AND NEED PERIODIC SCREENING

Question 206

Cranial Nerve Mnemonics for the names & S/M/B

Answer 206

Question 207

ROMBERG TEST

Normal: can walk tandem gait (heal to-toe) with balance, smooth, rhythmic, opposing arm swing is coordinated. Passed Romberg test, can do a shallow knee bend or hop in place

Abnormal: _________ (uncoordinated or steady gait), widened base, staggering, reeling, loss of balance, unequal rhythm of steps, slapping of foot, scraping of toe, __________ Romberg

Answer 207

Normal: can walk tandem gait (heal to-toe) with balance, smooth, rhythmic, opposing arm swing is coordinated. Passed Romberg test, can do a shallow knee bend or hop in place

Abnormal: ataxia (uncoordinated or steady gait), widened base, staggering, reeling, loss of balance, unequal rhythm of steps, slapping of foot, scraping of toe, positive Romberg

Question 208

______________ : place a familiar object in their hand, ask if they can identify it by touch

• Classic test for Alzheimer’s
• Abnormal: astereognosis (unable to identify object, occurs in sensory cortex lesions)

Answer 208

Stereognosis

Question 209

______________ : write a number in their hand, ask if they can identify by touch
* Classic test for assessing Alzheimer’s

Answer 209

Graphesthesia

Question 210

__________________________
distance at which two points are felt
* More precise the closer you are to the fingertips

Answer 210

Two-point discrimination

Question 211

______________ DATA: MUSCULAR
* Joints
* Muscles
* Bones
* Functional - ADLs
* Patient-centered care

Answer 211

SUBJECTIVE

Question 212

RANGE OF MOTION - ROM

Answer 212

Question 213

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

A. Decreased in the older adult
B. Impaired in a patient with cataracts
C. Stimulated by cranial nerves I and II.
D. Stimulated by cranial nerves III, IV, and VI.

Answer 213

D. Stimulated by cranial nerves III, IV, and VI.

Question 214

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________.

A. XI; palpating the anterior and posterior triangles
B. XI; asking the patient to shrug her shoulders against resistance
C. XII; percussing the sternomastoid and submandibular neck muscles
D. XII; assessing for a positive Romberg sign

Answer 214

B. XI; asking the patient to shrug her shoulders against resistance

Question 215

The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)?

A. Flexion and extension
B. Supination and pronation
C. Circumduction
D. Inversion and eversion

Answer 215

A. Flexion and extension

Question 216

A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope.

A. Low gurgling; diaphragm
B. Loud, whooshing, blowing; bell
C. Soft, whooshing, pulsatile; bell
D. High-pitched tinkling; diaphragm

Answer 216

C. Soft, whooshing, pulsatile; bell

Question 217

If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a _______, which is a soft, pulsatile, whooshing, blowing sound, heard best with the bell of the stethoscope.

Answer 217

bruit

Question 218

A patient states “I can hear a crunching or grating sound when I kneel”. She also states “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints”. The nurse should assess for signs of what problem?

A. Crepitation
B. Bone spur
C. Loose tendon
D. Fluid in the knee joint

Answer 218

A. Crepitation

Question 219

_______________ is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid
arthritis

Answer 219

Crepitation

Question 220

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

A. Ataxia.
B. Lack of coordination.
C. Negative Homans sign.
D. Positive Romberg sign.

Answer 220

D. Positive Romberg sign.

Question 221

Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling.

A positive Romberg sign is a loss of _________ that is increased by the closing of the eyes.

Answer 221

balance

Question 222

_________ is an uncoordinated or unsteady gait.

Answer 222

Ataxia

Question 223

_________ sign is used to test the legs for deep-vein thrombosis.

Answer 223

Homans

Question 224

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right- sided weakness. What might the nurse expect to find when testing his reflexes on the right side?

A. Lack of reflexes
B. Normal reflexes
C. Diminished reflexes
D. Hyperactive reflexes

Answer 224

D. Hyperactive reflexes

Question 225

_________________ is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor
neuron lesions

Answer 225

Hyperreflexia

Question 226

Precentral gyrus- primary ________ area

Answer 226

motor

Question 227

Postcentral gyrus- primary ___________ area

Answer 227

sensory

Question 228

Parietal lobe- ___________

Answer 228

sensation

Question 229

__________ area- speech comprehension

Answer 229

wernicke’s

Question 230

occipital lobe- ________ reception

Answer 230

visual

Question 231

_____________ - motor coordination, equilibrium, balance

Answer 231

cerebellum

Question 232

___________ lobe- hearing, taste, smell

Answer 232

temporal

Question 233

________ area- motor speech

Answer 233

broca’s

Question 234

___________ lobe- personality, behavior, emotion, intellectual functions

Answer 234

frontal

Question 235

A patient comes in for a physical examination and complains of freezing to death while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:

a. Venous pooling.
b. Peripheral vasodilation.
c. Peripheral vasoconstriction.
d. Decreased arterial perfusion.

Answer 235

C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness

Question 236

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

a.Decreased fluid volume.
b.Increased cardiac output.
c.Narrowing of jugular veins.
d.Elevated pressure related to heart failure.

Answer 236

d.Elevated pressure related to heart failure.

Question 237

A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:
a. Flexion.
b. Abduction.
c. Adduction.
d. Extension.

Answer 237

c. Adduction.

Question 238

A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph-

Which action should the nurse take next?
a. Contact the provider with this abnormal finding.
b. Assess bilateral legs for temperature and edema.
c. Ask the client about pain in the lower leg and calf.
d. Document the finding and continue the assessment.

Answer 238

a. Contact the provider with this abnormal finding. (correct)

Question 239

The nurse notices that a patient’s palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to cranial nerve:

Answer 239

VII - Facial

Facial muscles are mediated by cranial nerve (CN) VII;

Question 240

asymmetry of palpebral fissures may be due to CN VII damage (______________)

Answer 240

(Bell’s palsy)

Question 241

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects damage to which nerve?

Answer 241

trigeminal nerve.

• Facial sensations of pain or touch are mediated by cranial nerve (CN) V trigeminal nerve.

Question 242

When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________________________ glands.

Answer 242

parotid and submandibular

• Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are not normally palpable.

Question 243

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

Answer 243

XI; asking the patient to shrug her shoulders against resistance

• The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

Question 244

When examining a patient’s cranial nerve (CN) function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:

Answer 244

sternomastoid and trapezius.

• The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory

Question 245

A patient’s laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the _____ gland.

Answer 245

thyroid

• The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and tri-iodothyronine (T3). The other glands do not secrete thyroxine.

Question 246

The nurse is aware that the four areas in the body where lymph nodes are accessible are the:

Answer 246

head and neck, arms, inguinal area, and axillae.

• Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

Question 247

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:

Answer 247

firm but freely movable.

• Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

Question 248

The inability to identify vibrations at the ankle and to identify the position of the big toe, along with a slower and more deliberate gait, and slightly impaired tactile sensation in an 80yo patient means

Answer 248

Sensory and motor deficits commonly associated with aging

Question 249

A 70yo patient tells the nurse that every time they get up in the morning or after they’ve been sitting for a while, they get “really dizzy” and feel like they are going to fall over. What is the best response by the nurse?

Answer 249

“You need to get up slowly when you’ve been lying down or sitting”

Question 250

Cyanosis: This is a _______ mottled color from decreased perfusion; the tissues have high levels of deoxygenated blood

Answer 250

bluish

Question 251

Pallor: when the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly _______.

Answer 251

white

Question 252

Jaundice: A ____________ skin color indicates rising amounts of bilirubin in the blood

Answer 252

yellowish

Question 253

Erythema: intense ___________ of the skin is from excess blood (hyperemia) in the dilated superficial capillaries.

Answer 253

redness

Question 254

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:

Answer 254

refer the patient because of the suspicion of melanoma on the basis of her symptoms.

Question 255

The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person’s:

Answer 255

circulatory status.

The skin holds information about the body’s circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

Question 256

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?

Answer 256

Clubbing of the nails

Clubbing of the nails occurs with cogenotal cyanotic hearty disease and neoplase and pulmonary disease. the other responses are assessment findings not assiciated with pulmonary diseases

Question 257

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient’s scleras are not yellow. From this finding, the nurse could probably rule out:

Answer 257

jaundice

Question 258

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

Answer 258

An increased loss of elastin and a decrease in subcutaneous fat in the elderly