Health Assessment Exam 2 – Flashcards
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A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? A) Inspect the palpebral conjunctiva B) Assess the nasolacrimal sac C) Perform the eye positions test D) Test pupillary reaction to light
answer
b
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When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following? A) Physiologic cup B) Optic disc C) Retinal vessels D) Fovea
answer
b
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A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following? A) Direct reflex B) Optic chiasm C) Consensual response D) Accommodation
answer
c
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The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? A) Far, then near B) Lateral, then near C) Near, then far D) Lateral, then far
answer
a
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During a health history, a 42-year-old male client reveals that he is seeing spots before his eyes. The nurse interprets this finding as the result of which of the following? A) Increased ocular pressure B) Vitamin A deficiency C) Normal findings for client's age D) Vascular spasm
answer
c
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A nurse is caring for several clients. Which client would be at the highest risk for developing cataracts? A) A 55-year-old female client B) A 40-year-old with arteriosclerosis C) A client whose father had cataracts D) A male client who smokes cigarettes
answer
a
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When performing the cover test, the nurse would cover one of the client's eyes and then ask the client to do which of the following? A) Focus on a distant object, looking for movement in the other eye B) Close the other eye, then open that eye quickly C) Follow the examiner's finger with the other eye D) Look directly at a light with the other eye
answer
a
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Which of the following would a nurse expect to assess in a client with esotropia? A) Eye turning outward B) Eye malalignment C) Eye turning inward D) Eye oscillating
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c
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Which test would be most appropriate for the nurse to perform when assessing eye muscle strength and cranial nerve function? A) Corneal light reflex test B) Eye positions test C) Cover test D) Visual fields test
answer
b
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A nurse examines an older adult client. Which of the following would the nurse document as a normal finding? A) Ectropion B) Episcleritis C) Chalazion D) Exophthalmos
answer
a
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Which of the following would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies? A) Generalized redness B) Pinguecula C) Areas of dryness D) Nodular appearance
answer
c
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When testing for consensual pupillary constriction, which technique would be most appropriate? A) Hold a pencil about 12 inches from the tip of the nose B) Use an ophthalmoscope to inspect the inner eye C) Shine a light directly into one eye of the client D) Place a barrier between the client's eyes
answer
d
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A nurse is assessing the eyes of a young child. Which finding would the nurse document as normal? A) Pseudostrabismus B) Tropia C) Nystagmus D) Exotropia
answer
a
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A review of a client's history reveals cranial nerve IV paralysis. Which of the following would the nurse assess? A) The eye cannot look to the outside side. B) Ptosis will be evident. C) The eye cannot look down when turned inward. D) The eye will look straight ahead.
answer
c
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When observing the red reflex in a client who says, "I hope you can see it because I have cataracts," which of the following would the nurse find? A) Black spokes pointing inward B) White arc around the limbus C) Thickened bulbar conjunctiva D) A red spot on the retina
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a
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A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? A) Recent eye trauma B) Narcotic use C) Effects of deep anesthesia D) Recent central nervous system injury
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b
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Which of the following would the nurse assess when optic atrophy is suspected? A) Obscured retinal vessels B) No visible physiologic cup C) Increased appearance of the disc vessels D) A white appearance of the optic disc
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d
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What would be an expected finding when performing an eye positions test on a client has an inner ear infection? A) Strabismus B) Phoria C) Tropia D) Nystagmus
answer
d
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After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? Select all that apply. A) Lacrimal apparatus B) Conjunctiva C) Lens D) Iris E) Sclera
answer
a, b, f
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A nurse is presenting a class to a local community about vision and eye health. As part of the presentation the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation? A) Refers to what a person sees with one eye B) Involves light rays striking the retina C) Acts as a protective reflex to limit light D) Allows the eyes to focus on near objects
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b
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The nurse tests the distant visual acuity of several clients and records the findings. Which finding indicates that the client with the poorest vision? A) 20/30 B) 20/40 C) 20/50 D) 20/60
answer
d
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A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? A) Ask the client to remove the glasses before testing. B) Have the client keep the glasses on but occlude one eye. C) Test the client's near visual acuity instead. D) Use the E chart rather than the Snellen chart for testing.
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a
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The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform? A) Cover test B) Corneal light reflex test C) Confrontation test D) Eye position test
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c
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During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect? A) Myopia B) Presbyopia C) Cataracts D) Tropia
answer
b
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Inspection of a client's eyelids reveals significant lid swelling, moderate redness, but little pain. Which of the following would the nurse suspect? A) Blepharitis B) Hordeolum C) Chalazion D) Exophthalmos
answer
c
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A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal? A) Raised yellow plaques near inner canthus B) Upright lower eyelid C) Drooping of the upper lid D) White sclera absent above iris
answer
c
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The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal? A) 2 mm B) 4 mm C) 6 mm D) 8 mm
answer
b
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When using the ophthalmoscope, which of the following would the nurse do? A) Use the small round beam of white light B) Use the right eye to examine the client's left eye C) Move the ophthalmoscope around to get the best view D) Approach the client at a 15-degree angle to the client's side
answer
d
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After teaching a group of students about visual fields and visual pathways, the instructor determines that the teaching was successful when the students identify which of the following? A) The optic nerves from each eyeball cross at the optic chiasma. B) The visual field of each eye is divided into six quadrants. C) The left side of the brain views the right side of the world. D) The visual field of each eye provides a separate, distinct view.
answer
a
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A nurse examines a client's retina and finds cotton-wool patches. Which of the following would the nurse suspect? A) Glaucoma B) Diabetes mellitus C) Papilledema D) Optic atrophy
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b
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When assessing the ear, which finding would be cause for concern? A) Darwin tubercle B) Red, flaky cerumen C) Tender tragus D) Pearly gray tympanic membrane
answer
c
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A client asks why cerumen is important because it "just clogs up the ear anyway." Which response would be most appropriate? A) "It helps create the smoothness of the external auditory canal." B) "It helps keep the tympanic membrane soft." C) "It helps conduct sound waves through the inner ear." D) "It helps create the translucent, pearly color of the eardrum."
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b
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The nurse would suspect a problem at which area when pressure builds up on either side of the tympanic membrane? A) Cochlea B) Eustachian tube C) Vestibulocochlear nerve D) Organ of Corti
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b
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A client has a sensorineural hearing loss. Which condition would the nurse most likely identify as a cause? A) Perforated eardrum B) Otosclerosis C) Inner ear problem D) Otitis media
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c
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A 55-year-old client is being evaluated for a hearing impairment. Which question would be most appropriate to provide the most useful information? A) "Are you having difficulty hearing high-frequency sounds?" B) "Do you notice any drainage from your ears?" C) "Are you experiencing any pain in your ears?" D) "Have you felt any popping sensations?"
answer
a
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A client presents with purulent, bloody drainage of the ear. Which of the following would the nurse assess first? A) Assess the tympanic membrane. B) Ask whether there is any pain in the ear. C) Inspect the external ear canal. D) Ask whether the client has experienced any hearing loss.
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c
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A 60-year-old client has difficulty hearing high-pitched sounds. The nurse would document this finding as which of the following? A) Vertigo B) Otalgia C) Tinnitus D) Presbycusis
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d
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A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing? A) Minimizing the amount of noise exposure to 3 hours a day B) Taking a 10-minute break every 2 hours C) Wearing ear guards whenever inside the plant D) Cleaning ears regularly to prevent ear infections
answer
c
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A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following? A) Otitis media B) Otitis externa C) Ruptured tympanic membrane D) Mastoiditis
answer
b
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The nurse notes a clear, watery discharge from the client's external ear canal following a motor vehicle accident. Which of the following would the nurse do next? A) Refer the client immediately for further evaluation B) Assess for foreign body impaction C) Look for postauricular cysts D) Assess for cream-colored nodules on the helix
answer
a
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While assessing the ears of an 8-year-old client, the nurse observes white spots on the tympanic membrane with no redness present. Which action would be most appropriate? A) Assess the client for trauma to the skull. B) Determine whether impacted cerumen is present. C) Ask the mother whether the child has had numerous ear infections. D) Assess the child for further symptoms of acute otitis media.
answer
c
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After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative? A) Client moves the feet apart during the exam B) Client sways moderately during the exam C) Client maintains the position during the exam D) Client starts to lose balance during the exam
answer
c
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The results of a Rinne test show bone conduction is greater than air conduction. Which of the following would be most appropriate? A) Complete a full hearing assessment B) Generate a nursing diagnosis so interventions may be initiated C) Write an initial plan of care and evaluate the results in 24-hours D) Refer the client for further evaluation
answer
d
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The following data are gathered: speaks very softly, denies hearing loss, has never had and cannot afford additional hearing tests, fails whisper test. Which nursing diagnosis would be most appropriate? A) Ineffective health maintenance, related to denial of hearing problem and inadequate resources for additional testing B) Impaired social interaction, related to decreased ability to maintain contact with friends C) Impaired verbal communication, related to lack of understanding of hearing deficit D) Readiness for enhanced communication relate to auditory integrity and never having had hearing tests
answer
a
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The nurse is assessing several clients. Which client is at greatest risk for developing a hearing loss? A) A client with multiple sclerosis B) A 40-year-old African American female client C) A client with occasional tinnitus D) A client who ear protection frequently at work
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a
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Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client? A) Keeping the dominant hand away from the client's head B) Inserting the speculum down and forward into the ear canal C) Using the smallest speculum on the otoscope head D) Holding the otoscope in the non-dominant hand
answer
b
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During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following? A) The good ear cannot receive sound vibrations. B) There is a dysfunction of the middle ear. C) The poor ear is receiving sound vibrations by air. D) There is a sensorineural hearing impairment.
answer
d
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A nurse is performing an otoscopic exam of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place? A) In the center of the membrane B) In the 5-o'clock position C) In the 7-o'clock position D) In the upper left quadrant
answer
b
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While inspecting the tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? A) Scarring from previous infections B) Serous otitis media C) Normal tympanic membrane D) Acute otitis media
answer
c
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A 53-year-old client with a sensorineural hearing loss asks the nurse how this occurred. Which of the following responses would be most appropriate? A) "This is not uncommon in people your age because your eardrum is hardening." B) "You probably have a lot of wax buildup that is interfering with hearing sounds." C) "Your work in the factory exposed you to loud noises over a long time." D) "You have a history of fluid building up in your middle ear, which is responsible."
answer
c
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The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first? A) Center of client's forehead B) On the mastoid process C) In front of the external auditory canal D) At the base of the skull
answer
b
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A group of students is reviewing the structures of the ear in preparation for test. The students demonstrate understanding of the material when they identify which structure as part of the middle ear? A) Tympanic membrane B) Pinna C) Cochlea D) Malleus
answer
d
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A nurse is preparing a class for a group of parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to this infection than adults. Which of the following would the nurse include? A) Children have a tendency to stick things in their ears. B) Their eustachian tube is shorter, straighter, and narrower. C) Their immune systems lack the maturity to fight the infections. D) Children aren't able to perform hand-washing as meticulously.
answer
b
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Which of the following, if obtained during the health history, would alert the nurse to a possible ear-related problem? A) Absence of drainage B) Use of cotton swabs inside the ear C) Earplug use when swimming D) Ear infection one time at age 3
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b
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The nurse is preparing to examine a client's internal ear. Which equipment would be necessary? A) Watch with a second hand B) Tuning fork C) Otoscope D) Measuring tape
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c
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Which finding, if noted when inspecting a client's mouth, would require immediate follow-up? A) Thrush B) Leukoplakia C) Koplik spots D) Canker sore
answer
b
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During the history a client reports a blockage in the upper portion of the nasal passage. Which of the following would the nurse expect as a prominent symptom? A) Decreased sense of taste B) Difficulty hearing C) Inability to smell D) Occasional dizziness
answer
c
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A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information? A) History of allergies B) History of dysphagia C) Frequency of nosebleeds D) Tonsillar enlargement
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a
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The nurse is preparing to teach a class to a group of clients with dysphagia. Which of the following would be most important for the nurse to include? A) Brush the tongue twice a day to prevent bad breath. B) The condition can lead to temporomandibular joint pain. C) Thoroughly chew only small amounts of food with each mouthful. D) Regular dental exams are very important.
answer
c
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When examining the mouth of a client, the nurse notes a bluish-black line along the gum line. Which action would be the priority? A) Determining whether the client is receiving phenytoin therapy B) Referring the client for further evaluation C) Encouraging the client to enroll in a smoking cessation program D) Providing the client with information on proper mouth care
answer
b
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While examining a client, the nurse notes fasciculation of the tongue. Which of the following would the nurse do next? A) Have the client do a 24-hour diet recall B) Review the client's medication regimen C) Prepare the client for a thyroid screening D) Assess the client's cranial nerves
answer
d
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A client with postnasal sinus drainage is seen in the clinic. When assessing the throat, the nurse would anticipate seeing which color drainage? A) Green B) Clear C) Gray D) Yellow
answer
d
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A client has a sinus infection with large amounts of exudate. Which of the following assessment findings would be most likely? A) Crepitus over the maxillary sinuses B) Frontal sinuses nontender to palpation C) Red, tender tympanic membrane D) Increased amounts of cerumen
answer
a
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The nurse is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
answer
c
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A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A) III B) VI C) VIII D) XII
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d
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When examining a young client who complains of a sore throat, the nurse notes swelling on either side of the oropharynx. The nurse would include which of the following when documenting this finding? A) Enlarged pharyngeal tonsils B) Enlarged palatine tonsils C) Enlarged adenoids D) Enlarged lingual tonsils
answer
b
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An older adult client with receding gums comes to the clinic. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask? A) "Have you lost any teeth recently?" B) "Do you have any difficulty chewing food?" C) "Have you had any mouth sores recently?" D) "Are you able to taste the food you eat?"
answer
a
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Which of the following would be most important to assess when a client is noted to be a mouth breather? A) Asking if the client experiences dry mouth often B) Inspecting for dental caries C) Checking for deviated nasal septum D) Asking what other symptoms the client is experiencing
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c
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The nurse would assess for which of the following after noting circumoral cyanosis in a client? A) Changes in vital signs B) Ketoacidosis C) Carbon monoxide poisoning D) Allergic reaction
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a
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While checking the preadmission history, the nurse notes that the client's history reveals deep tongue fissures. Which of the following orders would take priority? A) Anterior-posterior and lateral chest x-ray B) Complete blood count with differential C) Dietitian referral D) Intravenous fluid replacement
answer
d
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The nurse assesses thick white plaques on the hard palate of a client. Which of the following would the nurse do next? A) Further evaluate for AIDS. B) Refer the client for medication. C) Asses laboratory values for zinc deficiency. D) Assess the client for signs of jaundice.
answer
b
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A client is noted to have a bifid uvula. The nurse understands that this finding is most common in which ethnic group? A) Italian Americans B) Native Americans C) African Americans D) Non-Hispanic Americans
answer
b
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A line across the tip of the nose is seen in an 8-year-old client. The nurse would focus on which area of assessment? A) History of abuse B) Chronic nose picking C) Mucosal polyps D) Chronic allergies
answer
d
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A client complains of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse anticipates which of the following? A) The physician will write a prescription for antibiotics. B) The drainage will need to be cultured. C) A repeat procedure will be done in 1 week to compare findings. D) The headaches are most likely not from a sinus infection.
answer
d
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A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as a component of saliva? Select all that apply. A) Salts B) Proteins C) Fats D) Mucus E) Amylase
answer
a, d, e
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A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching? A) "Increase your intake of foods high in iron and zinc." B) "Avoid substances that could be irritating to your mouth." C) "Make sure to get lots of vitamin from the sun." D) "Use a humidifier to increase the moisture in the environment."
answer
b
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The nurse is inspecting Wharton's ducts. The nurse would expect to find these at which location? A) Either side of frenulum on floor of the mouth B) Ventral surface of the tongue C) Buccal mucosa across from the second upper molars D) At the back of the mouth midline of the soft palate
answer
a
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Which of the following would a nurse document as a normal finding? A) Negative red glow on transillumination of sinuses B) Nasal mucosa pale pink and swollen C) Tonsils 2+ D) Torus palatinus
answer
d
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After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw? A) Frontal B) Maxillary C) Ethmoidal D) Sphenoidal
answer
b
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When assessing a client for possible oral cancer, the nurse would closely inspect which area? A) Buccal mucosa B) Hard palate C) Area under the tongue D) Along the gum line
answer
c
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When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following? A) Softly repeat the words "one-two-three." B) Say "ninety-nine." C) Cough each time the stethoscope is moved. D) Say the letter "e."
answer
a
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When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start? A) Sternum B) Suprasternal notch C) Sternal angle D) Sternal border
answer
c
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What would the nurse expect to hear when auscultating the lungs of a client who is dehydrated? A) Friction rub B) Decreased breath sounds C) Sibilant wheeze D) Stridor
answer
a
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A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort? A) There is loss of involuntary respiratory control. B) The client will respond negatively to increased stimuli. C) There is an increased level of carbon dioxide in the blood. D) The client's oxygen levels in the blood will be increased.
answer
a
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During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following? A) Pneumonia B) Tuberculosis C) Bronchitis D) Heart failure
answer
d
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A client is diagnosed with pulmonary edema. The nurse would most likely assess the sputum color as which of the following? A) White B) Yellow C) Pink D) Rust
answer
c
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A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next? A) Ask how long ago he was diagnosed. B) Ask about any medications being used for hypertension. C) Refer him for further evaluation. D) Perform a complete respiratory assessment.
answer
b
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Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following? A) Diabetes mellitus B) Heart failure C) Chronic obstructive pulmonary disease D) System lupus erythematosus
answer
c
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Which of the following would the nurse assess in a client with severe upper respiratory pneumonia? A) Pursed lip breathing B) Pain over the ribs C) Crepitus on palpation D) Increased warmth of the skin
answer
c
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The nurse assesses chest expansion in a young adult and finds it to be 8 cm. The nurse documents this as which of the following? A) Limited expansion B) Normal expansion C) Hypoexpansion D) Hyperexpansion
answer
b
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A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following? A) Hyperresonance B) Dullness C) Resonance D) Tympany
answer
a
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Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? A) Refer the client for further medical evaluation B) Auscultate for egophony C) Perform bronchophony D) Have the client cough, then listen again
answer
d
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While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following? A) Pneumonia B) Pectus excavatum C) Funnel chest D) Emphysema
answer
d
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A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect? A) Diabetic ketoacidosis B) Renal failure C) Narcotic overdose D) Severe brain damage
answer
d
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Which of the following would be most important for the nurse to remember when auscultating the thorax? A) Listen at each site for at least one complete respiratory cycle B) Have the client breathe deeply through the mouth C) Be alert to the client's comfort and offer rest periods D) Auscultate the base at the level of the sixth rib
answer
a
question
A client is diagnosed with bronchitis. Which of the following would the nurse hear on auscultation? A) Sibilant wheezes B) Fine crackles C) Sonorous wheezes D) Coarse crackles
answer
c
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The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following? A) Client is hypoventilating B) Client may have overdosed on narcotics C) The pattern is expected with this condition D) These are normal Kussmaul's respirations
answer
c
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What type of respiratory pattern would the nurse consider normal in a client with severe heart failure? A) Biot's B) Bradypnea C) Kussmaul's D) Cheyne-Stokes
answer
d
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The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following would the nurse assess next? A) Lateral aspect of the thorax. B) Lung volume C) Hip levels D) Spinal column
answer
d
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While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document this as which of the following? A) Vesicular breath sounds B) Bronchovesicular breath sounds C) Adventitious breath sounds D) Bronchial breath sounds
answer
d
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When percussing the scapula of a client, which of the following would the nurse expect to hear? A) Resonance B) Dullness C) Flatness D) Hyperresonance
answer
c
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A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax? A) Midaxillary line B) Vertebral line C) Right midclavicular line D) Sternal line
answer
b
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When assessing the apices of the lungs, the nurse would locate them at which position? A) At the level of the diaphragm B) Near the level of the eighth rib C) Slightly above the clavicle D) At about the tenth rib
answer
c
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The nurse is assessing the various lobes of the lungs. The nurse must assess which lobe anteriorly? A) Left upper lobe B) Left lower lobe C) Right upper lobe D) Right middle lobe
answer
d
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A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following? A) Fremitus B) Egophony C) Chest expansion D) Bronchophony
answer
a
question
A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which race would the instructor identify as having a larger thorax? A) African Americans B) Asian Americans C) Native Americans D) Caucasians
answer
d
question
After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following as an age-related change? A) Increased resiliency B) Loss of elasticity C) Increased functional capillaries D) Loss of subcutaneous fat
answer
b
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A group of students is studying for a test about lung cancer. The students demonstrate understanding of the material when they identify which of the following as risk factors? Select all that apply. A) Asian American heritage B) Female gender C) Exposure to arsenic D) Use of beta carotene supplements E) Cold dry air F) Diet high in fruits and vegetables
answer
b, c, d
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Which of the following would be best for a nurse to use when assessing for fremitus in a client? A) Dorsal hand surface B) Pads of fingers C) Ball of hand D) Fist
answer
c
question
The nurse is preparing to auscultate the breaths sounds of a client's anterior chest. The nurse notes that the client's chest has a large amount of hair on it. Which of the following would the nurse do? A) Give the client a razor and soap and ask him to shave the hair on his chest B) Have the client put his T-shirt back on and auscultate through the shirt C) Omit this part of the assessment and document this D) Have the client breath more forcibly during the exam and listen with the bell
answer
b
question
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location? A) On each side of the client's face, anterior and inferior to the ears B) On each side between the top of the ear and the eye C) Bilaterally, parallel to and anterior to the sternomastoid muscle D) Inferior to the mandible beneath the tongue
answer
d
question
Which of the following would the nurse avoid when assessing a client's carotid pulses? A) Asking the client to flex the neck B) Compressing the arteries bilaterally C) Performing the examination while the client is seated D) Asking the client to swallow water
answer
b
question
A male client can neither turn his head against resistance nor shrug his shoulders. The nurse documents a deficit in the functioning of which cranial nerve? A) Abducens (VI) B) Accessory (XI) C) Hypoglossal (XII) D) Trochlear (IV)
answer
b
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During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following? A) Trigeminal neuralgia B) Migraine headache C) Meningitis D) Temporomandibular joint dysfunction
answer
a
question
A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines? A) "Do they occur after you have been tense or anxious?" B) "When you consume alcohol, do you get a headache?" C) "Do you have any eye symptoms, such as tearing?" D) "Do you have any visual changes before the headache?"
answer
d
question
Which factor if present in a client's lifestyle and health practices assessment would alert the nurse to the need for performing a more thorough head and neck assessment? A) Alcohol abuse B) Recreational drug use C) Smokeless tobacco use D) Multiple sex partners
answer
c
question
A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? A) Correct use of firearms B) Defensive driving C) Fall prevention D) Domestic violence prevention
answer
c
question
Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal? A) Acromegaly B) Brain tumor C) Paget disease D) Parkinson disease
answer
a
question
When talking to a client before starting the physical exam, the nurse notes that the client's head is tilted to one side. Which of the following would the nurse examine first? A) Hearing acuity B) Thyroid gland C) Mental status D) Lymph nodes
answer
a
question
The nurse examines a client and assesses a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which area? A) Mental status B) Hearing C) Neurologic status D) Vision
answer
d
question
A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique? A) Inspection B) Auscultation C) Palpation D) Percussion
answer
d
question
A nurse is palpating the position of the trachea. At which anatomic site would the nurse first position a finger for palpation? A) Sternocleidomastoid muscle B) Sternal notch C) Submental space D) Supraclavicular space
answer
b
question
When examining a client's thyroid gland, the nurse ensures that which equipment is readily available? A) Penlight B) Tongue depressor C) Centimeter-scale ruler D) Cup of water
answer
d
question
A nurse documents which of the following as a normal finding when examining the thyroid gland of an older adult client? A) Nodularity B) Tenderness C) Enlargement D) Bruits
answer
a
question
Which of the following would be most appropriate when auscultating the thyroid gland for bruits? A) Hyperextend the client's neck. B) Turn the client's head to the right. C) Have the client swallow water. D) Have the client hold his or her breath.
answer
d
question
At which location would a nurse palpate a client's submental lymph nodes? A) At the angle of the mandible B) Posterior base of the skull C) Area behind the ears D) Behind the tip of the mandible
answer
d
question
The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? A) Infraspinous B) Sternomastoid C) Trapezius D) Platysma
answer
b
question
Which of the following would the nurse document as an abnormal finding with lymph node assessment? A) Diameter: 0.75 cm B) Mobile C) Tender D) Discrete
answer
c
question
Which vessel is the nurse assessing if the major artery of the neck is being examined? A) Carotid B) Jugular C) Temporal D) Radial
answer
a
question
The nurse detects enlarged, tender, preauricular nodes in a client. Which of the following would the nurse need to examine for possible infection? A) Sinuses B) Teeth C) Eyes D) Lips
answer
c
question
A group of students are reviewing the structures of the head and neck in preparation for an examination. The students demonstrate understanding of the material when they identify that the face has how many bones? A) 8 B) 14 C) 18 D) 24
answer
b
question
A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes? A) 1 B) 2 C) 3 D) 4
answer
b
question
During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? A) Pain radiating from eye to temporal region B) Throbbing and severe pain C) Report of ringing in the ears prior to headache D) Additional complaint of sensitivity to light
answer
a
question
The nurse questions a client about any radiation therapy to the neck area based on the understanding about which of the following? A) Radiation therapy in that area can lead to enlarged lymph nodes. B) The client may not be able to flex and extend his neck for the examination. C) Radiation therapy has been linked to the development of thyroid cancer. D) The client may experience dizziness and light-headedness more easily.
answer
c
question
After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following? A) Firearm violence B) Female gender C) Contact sports D) Transportation accidents
answer
b
question
The nurse is assessing the face of a client with a history of Parkinson's disease. Which of the following would the nurse most likely assess? A) Sunken face B) Drooping of one side C) Masklike expression D) Asymmetry of earlobes
answer
c
