HEENT & Sensory Perception CORRECT 100%
The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse
should document this as being
1. cyanosis.
2. jaundice.
3. pallor.
4. erythema. - ANSWER 2
While performing an assessment of the integument system, the nurse notes the clients eyeballs are
protruding and the upper eyelids are elevated. What term should the nurse use to document this
finding?
1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic - ANSWER 3
The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed
assistive personnel?
1. Vital signs
2. Filling of water pitchers
3. Skull and face assessment
4. Ambulation of surgical clients - ANSWER 3
While performing a health assessment, in which position should the nurse place the client for inspection
of the jugular veins?
, 1. 90-degree angle
2. 30- to 45-degree angle
3. 15-degree angle
4. 60-degree angle - ANSWER 2
The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which
finding should the nurse report to the physician immediately?
1. Pulses equal bilaterally
2. Full pulsations
3. Thready pulses
4. Pulses present bilaterally - ANSWER 3
During the assessment of a clients breasts, the nurse finds both breasts rounded, slightly unequal in size,
skin smooth and intact, and nipples without discharge. What should the nurse do next?
1. Notify the charge nurse.
2. Notify the physician.
3. Document the findings in the nurses notes as normal.
4. Document the findings in the nurses notes as abnormal. - ANSWER 3
The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When
testing for muscle grip strength, the nurse should ask the client to perform which action?
1. Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out.
2. Hold an arm up and resist while the nurse tries to push it down.
3. Flex each arm and then try to extend it against the nurses attempt to keep the arm in flexion.
4. Shrug the shoulders against the resistance of the nurses hands. - ANSWER 1
The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse
should document this as being
1. cyanosis.
2. jaundice.
3. pallor.
4. erythema. - ANSWER 2
While performing an assessment of the integument system, the nurse notes the clients eyeballs are
protruding and the upper eyelids are elevated. What term should the nurse use to document this
finding?
1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic - ANSWER 3
The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed
assistive personnel?
1. Vital signs
2. Filling of water pitchers
3. Skull and face assessment
4. Ambulation of surgical clients - ANSWER 3
While performing a health assessment, in which position should the nurse place the client for inspection
of the jugular veins?
, 1. 90-degree angle
2. 30- to 45-degree angle
3. 15-degree angle
4. 60-degree angle - ANSWER 2
The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which
finding should the nurse report to the physician immediately?
1. Pulses equal bilaterally
2. Full pulsations
3. Thready pulses
4. Pulses present bilaterally - ANSWER 3
During the assessment of a clients breasts, the nurse finds both breasts rounded, slightly unequal in size,
skin smooth and intact, and nipples without discharge. What should the nurse do next?
1. Notify the charge nurse.
2. Notify the physician.
3. Document the findings in the nurses notes as normal.
4. Document the findings in the nurses notes as abnormal. - ANSWER 3
The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When
testing for muscle grip strength, the nurse should ask the client to perform which action?
1. Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out.
2. Hold an arm up and resist while the nurse tries to push it down.
3. Flex each arm and then try to extend it against the nurses attempt to keep the arm in flexion.
4. Shrug the shoulders against the resistance of the nurses hands. - ANSWER 1
