NUR 311 exam 2 Questions With Complete
Solutions
abdomen assessment Correct Answers I-inspect
A-auscultate
P- percussion
P- palpate
abdominal assessment subjective Correct Answers
-indigestion, anorexia, nausea, vomiting?
-abdominal pain?
-difficulty or pain swallowing?
-changes in bowel habits?
-constipation or diarrhea?
-changes in skin color or stool color?
-pain above pubic area?
-experience pain, urgency, or frequency of
urination?
-urinate more frequently than usual or during the
night?
-involuntary loss of urine?
-presence of blood in urine?
-flank pain?
abducens cranial nerve Correct Answers motor
anatomy: originate in the pons and supplied motor
fibers to the lateral rectus muscle
physiology: extraocular movements
,**lateral
assessment: assess pupils for size, shape, and
equality. assess six cardinal gazes of vision.
abnormal external eye structures Correct Answers
-eyebrows have unexplained hair loss (with normal
aging the outer third of the eyebrow thins)
-eyelashes curved inward toward the eye,
distributed unevenly along the lid margin, or both
-eyelids incompletely open or close, no
spontaneous blinking, improper positioning w/
respect to iris and limbus
-eye shape asymmetrical
-eyes not in parallel alignment (ptosis)
-lacrimal apparatus enlarged and/or tender
-erythema, cobblestone appearance, purulent
discharge, complete redness, and matting indicate
allergy or infection of bulbar conjunctiva
-abnormal thickening (pterygium) of bulbar
conjunctiva
-scleral redness, jaundice, bluing, and drainage
-lens cloudiness
-iris color not evenly distributed, noted vascularity
-pupil size less than 1 mm, aniscoria, marcus gunn
pupil, argyll robertson pupils, horner syndrome,
and oval pupils
abnormal lung assessment Correct Answers -
tripod position
,-anxious expression, lips pursed, irregular, labored,
gasping, grunting, or retracting respirations, and
nasal flaring
-irritable, drowsy, somnolent, restless, confused,
combative, or disoriented
-cyanosis, pallor, ruddy or reddish-purple facial
color
-forced expiration, guarding, effort or work of
breathing
-wheezing, tachypnea, bradypnea
-hypoxemia
-pallor or cyanosis of the nail beds. an angle of 180
degrees or more indicates clubbing
-barrel chest, AP to transverse ratio is 1:1 (round
chest). ribs slope more horizontally. asymmetry
and paradoxical respirations
-use of accessory muscles
-retractions present
-thorax is tender. lesions, lumps, masses, or
crepitus present
-asymmetrical movements
-decreased or absent tactile fremitus
-percussion sounds are dull, flat, or hyperresonant
-reduced diaphragmatic excursion
-presence of adventitious lung sounds (crackles,
wheezes, rhonchi)
-decreased or diminished lung sounds. absent
breath sounds
-clear and distinct bronchophony (louder over
denser areas), egophony, or whisper pectoriloquy
, -asymmetrical chest shape. deformities such as
pectus excavatum, pectus carinatum, etc. widened
of costal angle greater than 90 degrees
-use of accessory muscles
-retractions present
-tenderness on palpation
-asymmetrical lateral movement of the thumbs
-dullness percussed over lung tissue
accommodation Correct Answers the process by
which the eye's lens changes shape to focus near
or far objects on the retina
accurate documentation of pain Correct Answers -
location
**where is the pain?
-duration
**how long have you had the pain? when did it
start/go away?
-intensity
**0-10
-quality/description
**crampy, gnawing, burning, shooting, sharp, or
dull?
-alleviating/aggravating factors
**what makes it better/worse?
-pain management goal
**acceptable level of pain?
-functional goal
Solutions
abdomen assessment Correct Answers I-inspect
A-auscultate
P- percussion
P- palpate
abdominal assessment subjective Correct Answers
-indigestion, anorexia, nausea, vomiting?
-abdominal pain?
-difficulty or pain swallowing?
-changes in bowel habits?
-constipation or diarrhea?
-changes in skin color or stool color?
-pain above pubic area?
-experience pain, urgency, or frequency of
urination?
-urinate more frequently than usual or during the
night?
-involuntary loss of urine?
-presence of blood in urine?
-flank pain?
abducens cranial nerve Correct Answers motor
anatomy: originate in the pons and supplied motor
fibers to the lateral rectus muscle
physiology: extraocular movements
,**lateral
assessment: assess pupils for size, shape, and
equality. assess six cardinal gazes of vision.
abnormal external eye structures Correct Answers
-eyebrows have unexplained hair loss (with normal
aging the outer third of the eyebrow thins)
-eyelashes curved inward toward the eye,
distributed unevenly along the lid margin, or both
-eyelids incompletely open or close, no
spontaneous blinking, improper positioning w/
respect to iris and limbus
-eye shape asymmetrical
-eyes not in parallel alignment (ptosis)
-lacrimal apparatus enlarged and/or tender
-erythema, cobblestone appearance, purulent
discharge, complete redness, and matting indicate
allergy or infection of bulbar conjunctiva
-abnormal thickening (pterygium) of bulbar
conjunctiva
-scleral redness, jaundice, bluing, and drainage
-lens cloudiness
-iris color not evenly distributed, noted vascularity
-pupil size less than 1 mm, aniscoria, marcus gunn
pupil, argyll robertson pupils, horner syndrome,
and oval pupils
abnormal lung assessment Correct Answers -
tripod position
,-anxious expression, lips pursed, irregular, labored,
gasping, grunting, or retracting respirations, and
nasal flaring
-irritable, drowsy, somnolent, restless, confused,
combative, or disoriented
-cyanosis, pallor, ruddy or reddish-purple facial
color
-forced expiration, guarding, effort or work of
breathing
-wheezing, tachypnea, bradypnea
-hypoxemia
-pallor or cyanosis of the nail beds. an angle of 180
degrees or more indicates clubbing
-barrel chest, AP to transverse ratio is 1:1 (round
chest). ribs slope more horizontally. asymmetry
and paradoxical respirations
-use of accessory muscles
-retractions present
-thorax is tender. lesions, lumps, masses, or
crepitus present
-asymmetrical movements
-decreased or absent tactile fremitus
-percussion sounds are dull, flat, or hyperresonant
-reduced diaphragmatic excursion
-presence of adventitious lung sounds (crackles,
wheezes, rhonchi)
-decreased or diminished lung sounds. absent
breath sounds
-clear and distinct bronchophony (louder over
denser areas), egophony, or whisper pectoriloquy
, -asymmetrical chest shape. deformities such as
pectus excavatum, pectus carinatum, etc. widened
of costal angle greater than 90 degrees
-use of accessory muscles
-retractions present
-tenderness on palpation
-asymmetrical lateral movement of the thumbs
-dullness percussed over lung tissue
accommodation Correct Answers the process by
which the eye's lens changes shape to focus near
or far objects on the retina
accurate documentation of pain Correct Answers -
location
**where is the pain?
-duration
**how long have you had the pain? when did it
start/go away?
-intensity
**0-10
-quality/description
**crampy, gnawing, burning, shooting, sharp, or
dull?
-alleviating/aggravating factors
**what makes it better/worse?
-pain management goal
**acceptable level of pain?
-functional goal
