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Which of the following methods is correct for examining the ear of an adult patient with an otoscope? A. Gently pull the auricle up and back. B. Gently pull the auricle down and back. C. Use the largest speculum that will fit comfortably in the patient's ear. D. Both A and C. - - correct ans- - A. Gently pull the auricle up and back. C. Use the largest speculum that will fit comfortably in the patient's ear. Gently pulling the auricle up and back in the adult will straighten the auditory canal. Using the largest speculum that will fit comfortably is part of the otoscopic examination. Gently pulling the auricle down and back is the correct procedure for examining a child. A nurse is inspecting the patient's ears with an otoscope. Which of the following findings would be considered abnormal? A. Visible cone of light B. Pearly gray tympanic membrane C. Perforation of the tympanic membrane D. Small amount of cerumen - - correct ans- - C. Perforation of the tympanic membrane
The tympanic membrane should not have any perforations. A visible cone of light is a normal finding in an otoscopic examination. The tympanic membrane should appear pearly gray. A small amount of cerumen is a normal finding in an otoscopic examination. A whispered voice test includes which of the following? A. Having the patient wiggle a finger in the opposite ear. B. Whispering while standing 1 to 2 feet from the patient's ear. C. Playing soothing music in the examination room. D. Both A and B. - - correct ans- - A. Having the patient wiggle a finger in the opposite ear. B. Whispering while standing 1 to 2 feet from the patient's ear. Having the patient wiggle a finger in opposite ear ensures that patient is hearing the whisper in the ear being tested. A whispered voice test is performed while standing 1 to 2 feet from the patient's ear. Music can be a distraction or interference with a whispered voice test. Assessment of the ears includes which of the following? A. Inspection B. Palpation C. Examination with an otoscope D. All of the above - - correct ans- - A. Inspection B. Palpation C. Examination with an otoscope Which of the following is the correct way to assess a patient's nose for patency? A. Have the patient breathe rapidly through both nares.
Pressing the thumbs against the brow bones is the correct way to palpate the frontal sinuses. Pressing the thumbs along the sides of the nose is not the correct way to palpate the frontal sinuses. Pressing the bridge or the tip of the nose between the thumb and first finger is not the correct way to palpate the frontal sinuses. The gag reflex should be: A. Tested with a tongue blade on each side of the oropharynx B. Present on both sides C. Tested in the midline of the oropharynx only D. Both A and B - - correct ans- - A. Tested with a tongue blade on each side of the oropharynx B. Present on both sides Testing with a tongue blade on each side of the oropharynx is part of assessing the gag reflex. The gag reflex should be present on both sides. Testing with a tongue blade on each side of the oropharynx is part of assessing the gag reflex. There should be a bilateral response to the gag reflex. Testing in the midline of the oropharynx is not part of assessing the gag reflex Which structures are included in a complete assessment of the mouth? A. Lips, mucosa, teeth, and gums B. Tongue and floor of the mouth C. Hard and soft palates D. All of the above - - correct ans- - A. Lips, mucosa, teeth, and gums B. Tongue and floor of the mouth C. Hard and soft palates Lips, mucosa, teeth, gums, tongue, floor of the mouth, and hard and soft palates are all evaluated in a thorough assessment of the mouth. Lips, mucosa, teeth, and gums alone
are only part of a thorough assessment of the mouth. Tongue and floor of mouth alone are only part of a thorough assessment of the mouth. Hard and soft palates alone are only part of a thorough assessment of the mouth. What questions can you ask a patient to assess his or her state of consciousness? A. Ask the patient about his or her thoughts, feelings, and emotions. B. Ask for the date, his or her name, and the location. C. Ask the patient to repeat a series of five numbers. D. Ask the patient to write his or her name and address. - - correct ans- - B. Ask for the date, his or her name, and the location. Begin with asking the patient today's date, then ask the patient to state his or her name. A patient should be oriented to time, place, and person and be able to respond appropriately to questions about the environment. Thoughts, feelings, and emotions are not part of an assessment for state of consciousness. Repeating a series of numbers is not part of an assessment for state of consciousness. Having the ability to write his or her name and address is not part of an assessment for state of consciousness. Which of the following cranial nerves is assessed by holding a scented object under the patient's nose? A. Facial nerve B. Oculomotor nerve C. Olfactory nerve D. Acoustic nerve - - correct ans- - C. Olfactory nerve The olfactory nerve is assessed by having a patient close his or her eyes, inhale deeply, and identifying the smell. The facial nerve is assessed by observing the patient making specific facial movements. The oculomotor nerve is assessed by inspecting the eyelids and by checking the pupils. The acoustic nerve is assessed by performing the whispered voice test.
B. Having the patient swallow Both testing the gag reflex and having the patient swallow are part of a thorough assessment of the glossopharyngeal and vagus nerves. Testing the gag reflex is part of a thorough assessment of the glossopharyngeal and vagus nerves. When the posterior wall of the pharynx is touched, the patient should gag and the uvula should stay midline. Having the patient swallow is part of a thorough assessment of the glossopharyngeal and vagus nerves. Have the patient drink some water while you observe her ability to swallow. Touching the patient's face with dull and sharp instruments is not part of assessment of the glossopharyngeal and vagus nerves. Which test or tests assess accuracy of movement? A. Finger-to-finger test B. Finger-to-nose test C. Heel-to-shin test D. All of the above - - correct ans- - A. Finger-to-finger test B. Finger-to-nose test C. Heel-to-shin test All of the above tests can be used to assess accuracy of movement. The finger-to-finger test is used to assess accuracy of movement. The patient's movements should be rapid, smooth, and accurate with no past pointing. The finger-to-nose test is used to assess accuracy of movement. The patient's movements should be rapid, smooth, and accurate, even with increasing speed. The heel-to-shin test is used to assess accuracy of movement. The patient should move his heel in a straight line without deviations to the side. Which of the following are included in the assessment of mental status? A. Speech and language B. Emotional stability C. Physical appearance and behavior
D. All of the above - - correct ans- - A. Speech and language B. Emotional stability C. Physical appearance and behavior How would you assess sensitivity to superficial pain? A. Touch the patient with the sharp side of a broken tongue blade. B. Have the patient keep his or her eyes open. C. Allow 2 seconds between stimuli. D. Both A and C. - - correct ans- - A. Touch the patient with the sharp side of a broken tongue blade. C. Allow 2 seconds between stimuli. Touching the patient with the sharp side of a broken tongue blade and allowing 2 seconds between stimuli are both part of a thorough assessment for superficial pain sensation. Assessment of superficial pain can be done by touching the patient with the sharp side of a broken tongue blade. With the patient's eyes closed, ask the patient to identify if the sensation is dull or sharp. Assessment of superficial pain is performed with the patient's eyes closed. For assessment of superficial pain, randomly apply the sharp and dull stimuli, allowing 2 seconds between stimuli to avoid a summative effect. What should the nurse do if a patient displays staggering or loss of balance during the Romberg test? A. Give the patient a gentle push to further assess balance. B. Delay other balance tests. C. Have the patient stand on one foot with the eyes closed. D. Have the patient hop on one foot. - - correct ans- - B. Delay other balance tests. If a patient has staggering or loss of balance with the Romberg test, delay other balance tests. If a patient has staggering or loss of balance with the Romberg test, delay other
Reposition the client to her right side. Repositioning the client will not change the sound heard upon percussion of the lower abdomen. Observe the area for bladder distention. A dull sound upon percussion may be heard over a distended bladder. Determine if the client feels bloated or gaseous. Gaseous distention may cause a hyperresonant sound. Assist the client to a sitting position immediately. This action is not warranted in response to this finding. - - correct ans- - Observe the area for bladder distention. A dull sound upon percussion may be heard over a distended bladder. What action should the nurse take next? Move to the right upper quadrant (RUQ) to hear the sounds more distinctly. Irregular, high-pitched sounds are expected, so moving to another quadrant to hear more distinct sounds is not indicated. Continue to listen over the RLQ for 5 to 15 seconds. The pattern of bowel sounds is typically irregular and the duration of bowel sounds may range from 1 second to several seconds. Bowel sounds should be noted every 5 to 15 seconds. Change to the bell of the stethoscope to listen. The diaphragm of the stethoscope should be used to listen to bowel sounds.
Listen for 5 minutes before documenting the activity of the bowel sounds. If bowel sounds are not heard, the nurse should listen for 5 minutes to allow sufficient time before documenting the absence of bowel sounds. If bowel sounds are heard, it is not necessary to continue to listen for 5 minutes. - - correct ans- - Continue to listen over the RLQ for 5 to 15 seconds. The pattern of bowel sounds is typically irregular and the duration of bowel sounds may range from 1 second to several seconds. Bowel sounds should be noted every 5 to 15 seconds. The nurse's goal in palpating the client's abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the nurse take first? Deeply palpate each abdominal organ. Deep palpation of the organs is not the first step when palpating the abdomen. Carefully palpate areas of tenderness. Palpation of any areas of tenderness should be saved for last to prevent resulting discomfort or muscle rigidity. Lightly palpate the abdominal surface. Light palpation allows the nurse to screen the abdomen for any obvious masses or tenderness before applying deeper palpation that may cause pain or rigidity. Gently palpate the edges of the liver. Deep palpation used to palpate the liver is not the first step when screening the abdomen. - - correct ans- - Lightly palpate the abdominal surface. Light palpation allows the nurse to screen the abdomen for any obvious masses or tenderness before applying deeper palpation that may cause pain or rigidity. Which is the most appropriate follow up action the nurse should implement?
The presence of brown spots on the client's abdomen. This information will not directly impact the client's immediate care and is of less importance than other data. The presence of dullness in the suprapubic area. This information will not directly impact the client's immediate care and is of less importance than other data. What time the client received an antiemetic. This information is essential to report to the nurse assuming responsibility for the client to ensure client safety after receiving a sedating medication. The absence of a venous hum over the epigastric area. This is a normal finding and it does not impact the client's care. - - correct ans- - What time the client received an antiemetic. This information is essential to report to the nurse assuming responsibility for the client to ensure client safety after receiving a sedating medication. During report, the nurse also describes the client's earlier emesis. The nurse should describe the emesis in terms of which characteristics? Color. It is important for the nurse to describe the appearance of the emesis, which includes the color. Odor. It is important for the nurse to describe any odor of the emesis, which could indicate the presence of blood, undigested foods, or fecal contaminant. Intensity.
This is not characteristics of emesis. Volume. It is important for the nurse to describe the volume or amount of emesis. Duration. The duration will describe if the episodes of vomiting were short, sporadic, ongoing, or intermittent. - - correct ans- - Color. It is important for the nurse to describe the appearance of the emesis, which includes the color. Odor. It is important for the nurse to describe any odor of the emesis, which could indicate the presence of blood, undigested foods, or fecal contaminant. Volume. It is important for the nurse to describe the volume or amount of emesis. Duration. The duration will describe if the episodes of vomiting were short, sporadic, ongoing, or intermittent. When completing the pain assessment, how should the nurse assess for rebound tenderness? Position the client on her right side. It is not necessary to position the client on her side. Lightly palpate over the painful area.
This action is not useful following the onset of involuntary rigidity (guarding). - - correct ans- - Notify the HCP of the findings. Rebound tenderness and involuntary rigidity (guarding) are abnormal findings associated with peritoneal irritation and are signs that should be reported to the HCP immediately for further diagnostic evaluation. In response to the client's statement that she hurts a lot, what action should the nurse take first? Explain to the client that post-operative pain is normal. This is a non-therapeutic response to the client's current situation. Ask the client to describe her pain location and intensity. The nurse should begin by gathering further data about the pain, including location, intensity, and quality. Ask the client if she has passed gas since surgery. This question may be relevant, but other actions have priority. Assess the client's heart rate and blood pressure. This action may be warranted, but it is not the first action the nurse should implement when the client reports pain. - - correct ans- - Ask the client to describe her pain location and intensity. The nurse should begin by gathering further data about the pain, including location, intensity, and quality. Thirty minutes later, the nurse returns to assess Claudine's response to the medication. Which findings provide the best data about the effectiveness of the medication? The client's vital signs are within normal limits.
The client's vital signs (within normal limits) provide useful data about the client's response to pain. The client is holding a pillow over her abdomen. The client's actions may provide useful data about her response to pain, but they are not the most useful source of information about the effectiveness of an analgesic. The client's facial expression is calm and relaxed. The client's nonverbal behavior can provide valuable data about her response to pain, and it is a useful source of information about the effectiveness of an analgesic. The client states a lessening of her pain. The client's subjective report regarding her pain is important information for the nurse to assess when evaluating t - - correct ans- - The client's vital signs are within normal limits. The client's vital signs (within normal limits) provide useful data about the client's response to pain. The client's facial expression is calm and relaxed. The client's nonverbal behavior can provide valuable data about her response to pain, and it is a useful source of information about the effectiveness of an analgesic. The client states a lessening of her pain. The client's subjective report regarding her pain is important information for the nurse to assess when evaluating the effectiveness of analgesic administration. To learn about the intensity of the client's pain, what action should the nurse take? Ask the client how well she normally tolerates daily aches and pains. While this assessment is important, it does not provide information about the intensity of the client's pain.
Discontinuing further palpation is not warranted. - - correct ans- - Observe the muscles while the client exhales. Bilateral tensing is often an indication of voluntary guarding by the client. To help distinguish between voluntary and involuntary guarding, the nurse should observe the muscles during exhalation because the client usually does not demonstrate voluntary guarding during exhalation. 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 - - correct ans- - B. Midline trachea Midline trachea is an expected finding. Jugular vein distention, carotid artery prominence, and thyroid enlargement are not expected findings In which arteries are bruits considered normal? A. Carotid arteries B. Temporal arteries C. Aortic artery D. None of the above - - correct ans- - D. None of the above 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 - - correct ans- - C. Bruits in the temporal arteries
Bruits in the temporal arteries may indicate a vascular anomaly in the brain. Symmetrical facial features at rest, even distribution of hair, and symmetrical facial features with movement are expected findings. 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 - - correct ans- - D. All of the above Documentation of location, size, shape, consistency, tenderness, discreteness, and movability are all aspects of a thorough lymph node assessment. 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. - - correct ans- - D. Both comparing the lymph nodes bilaterally and providing privacy for the patient. Both comparing the lymph nodes bilaterally and providing privacy for the patient are important for lymph node assessment. Comparison to determine abnormality on one or both sides is important for lymph node assessment. Lymph nodes are palpated using the pads of the second and third fingers. Providing patient privacy is an important part of physical assessment
