Week 3 Flashcards
A nurse is assessing a patient’s neck with the patient seated. Which of the following is considered an unexpected finding?
Jugular vein distention
A nurse is inspecting the patient’s ears with an otoscope. Which of the following findings would be considered normal?
Small amount of cerumen
which arteries are bruits considered normal?
Presence of a bruit is a sign of arterial obstruction. It is not considered normal at any arterial site.
Neck rotation on each side should be
neck rotation should be 70 degrees on each side. Neck flexion and extension should each be 45 degrees.
Which of the following cranial nerves is assessed by observing the patient making specific facial movements?
Cranial nerve VII
The facial nerve (cranial nerve VII) is assessed by observing the patient making specific facial movements. Cranial Nerve XI is assessed by having the patient shrug against resistance. The olfactory nerve is assessed by having a patient close their eyes, inhale deeply, and identifying the smell. The acoustic nerve is assessed by performing the whispered voice test.
For which reflex is the normal response plantar flexion of the foot?
Achilles
What is the purpose of having the patient clench their teeth and smile?
It tests CN VII.
Which of the following is not included in a head-to-toe assessment?
Exercise stress test
Why is it important to have equipment and supplies organized before the exam?
It avoids interruptions and delays.
Which of the following is part of monitoring and care?
Ask the patient if they have any questions or concerns about the exam.
Which of the following techniques is used to assess muscle strength in a patient?
Apply an opposing force or resistance
What is an increased thoracic curvature, common in older persons, called?
Kyphosis
Neck flexion and extension should be
45 degrees.
Which of the following findings in a musculoskeletal assessment would be considered abnormal?
Both nodules and bogginess
What does a goniometer measure?
Angles of extension and flexion
Where is the apical impulse located?
In the fifth intercostal space at the midclavicular line
Auscultatory sites of the heart include
aortic, pulmonic, tricuspid, and mitral areas.
Which of the following findings during a cardiac assessment of an adult patient are considered normal?
S1 and S2 sounds
The S1 heart sound:
Is louder at the apex of the heart.
Results from closure of the mitral and tricuspid valves.
Marks the start of systole.
All of these choices. Correct
When auscultating for heart sounds, you would expect a S3 to sound like:
A “lub-dub-ee” or “Kentucky” sound
