Advanced Physical Assessment|NR 509 Week 7 Immersion Physical Assessment Questions-Answers

Advanced Physical Assessment|NR 509 Week 7 Immersion Physical Assessment Questions-AnswersQuestion: When performing a physical assessment, the first technique the nurse will always use Question: The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: Question: The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should … used to best assess the patient’s skin temperature? Question: Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? Question: The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed? Question: The nurse would use bimanual palpation technique in which situation? Question: The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ___________ of the underlying tissue. Question: The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if … by the new nurse, … that more review is … ? Question: When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: Question: The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? Question: The nurse hears bilateral loud, long and low tones when percussing over the lungs of a 4 year old child. The nurse should Question: A patient has suddenly developed shortness of breath and appears to … insignificant respiratory distress. After calling the position and placing the patient on oxygen, which of these actions is the best for the nurse to take went further assisting this patient? Question: The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? Question: The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: Question: Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: Question: The nurse will use which technique of assessment to determine the presence of crepitus, swelling and pulsations? Question: The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: Question: An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would … that the examination is being correctly performed? Question: The nurse is unable to palpate the right radial pulse on a patient. The best action would … to: Question: The nurse is preparing to perform a physical assessment. The correct action by the nurse is … by which statement? The nurse: Question: A man is at the clinic for a physical examination. He states that he is very anxious about the physical examination. What steps can the nurse take to make him more comfortable? Question: When performing a physical examination, safety must … considered to protect the examiner in the patient against the spread of the infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination ? Question: The nurses examining a patient lower leg and notices a training ulceration. Which of these actions is most appropriate in this situation? Question: During the examination offering some brief teaching about the patient’s body or examiners finding is often appropriate. Which one of these statements by the nurse is most appropriate? Question: The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing … physical examination is to help the: Question: The nurses examining an infant and prepares to elicit the Moro reflex at which time during the examination? Question: When preparing to perform a physical examination of the infant, the nurse should: Question: A 6-month-old infant has … to the well child clinic for a checkup. she is currently sleeping. What should the nurse do first when beginning the examination? Question: A 2-year-old child has … to the clinic for a well child checkup. the best way for the nurse to begin the assessment is to: Question: The nurses examining a 2-year-old child and asks may I listen to your heart now? Which critique of the nurse’s technique is most accurate Question: With which of these patients would it … most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on a pen light? Question: The nurse is preparing to examine a 4-year-old child. which action is appropriate for this age group? Question: When examining a 16-year-old male teenager, the nurse should: Question: When examining an older adult, the nurse should use which technique? Question: The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is too: Question: Which of the statements is true regarding the use of standard precautions in the health care setting? Question: The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? Question: When examining an instant, the nurse should examine which area first? Question: While auscultating heart sounds, the nurse here is a murmur. Which of these instruments should … used to assess this murmur? Question: During an examination of a patient abdomen, the nurse notes that the abdomen is rounded and firm to the touch period during percussion, the nurse notes a drum like quality of the sounds across the quadrants. this type of sound indicates: Question: The nurse is preparing to examine a 6-year-old child. which action is the most appropriate? Question: During auscultation of a patient’s heart sounds, the nurse here’s an unfamiliar sound. the nurse should: Question: The nurse is preparing to palpate the thorax and abdomen of a patient. which of these statements describes the correct technique for this procedure? select all that apply Question: The nurse is performing a general survey period which action is a component of the general survey? Question: When measuring a patients wait, the nurse is aware of which of these guidelines? Question: A patient’s weekly blood pressure readings for 2 months have ranged between 124/84 mmHg and 138/88 mmHg, with an average reading of 126/86 mmHg. The nurse knows that this blood pressure falls within which blood pressure category? Question: During an examination of a child, the nurse considers that physical growth is the best index of a child’s : Question: A one-month old infant has a head measurement of 34 centimeters and has a chest circumference of 32 centimeters. Based on the interpretation of these findings, the nurse would: Question: The nurse is assessing and 80-year-old male patient. which assessment findings would … considered normal? Question: The nurse should measure rectal temperatures in which of these patients? Question: The nurse is preparing to measure the length, wait, just, and head circumference of a 6 month old infant. Which measurement technique is correct? Question: The nurse knows that one advantage of the tympanic membrane thermometer is that: Question: When assessing an older adult, which vital signs changes occur with aging? Question: The nurses examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? Question: When measuring a patient’s body temperature, the nurse keeps in mind that the body temperature is … by : Question: When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult’s body temperature? Question: A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. he is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. the nurse knows that: Question: When assessing a 75 year old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. on the basis of this observation, the nurse should: Question: which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? Question: The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding the use of the TMT? Question: To assess a rectal temperature accurately in an adult, the nurse would: Question: Which technique is correct when the nurse is assessing the radial pulse of a patient? The post is … for: Question: When assessing a patient’s pulse comment the nurse should also notice which of these characteristics? Question: When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. the nurses next action would … to: Question: When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: Question: The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature 36 C, pulse 48 beats per minute, respirations 14 breaths per minute, blood pressure 104/68. Question: Which statement is true concerning these results? Question: The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory A patient’s blood pressure is 118/82 mmHg. He asks the nurse what do the numbers mean? The nurse’s pattern how should the nurse assess this child respirations? best reply is: Question: While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as _____, help determine blood pressure. Question: A nurse is helping at a health fair at a local mall. when taking blood pressures on a variety of people, the nurse keeps in mind that: Question: The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard sized blood pressure cuff. The nurse should expect the reading to: Question: A student is late for his appointment and has rushed across campus to the health clinic. the nurse should: Question: The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: Question: The nurse is taking an initial blood pressure reading on 72-year-old patient with documented hypertension. How should the nurse proceed? Question: The nurse has collected the following information on a patient; palpated blood pressure 180 mm Hg, auscultated blood pressure 170/100 mmHg, apical pulse 60 bpm, radial pulse 70bpm. What is the patients pulse pressure? Question: When auscultating the blood pressure of a 25 year old patient, the nurse notices the phase I Korotkoff sounds begin a 200mmHg. At 100mm Hg the Korotkoff sounds muffle. At 92mmHg the Korotkoff sounds disappear. How should the nurse record this patients blood pressure? Question: A patient is seen them in clinic for complaints of painting episodes that started last week period How should the nurse proceed with the examination? Question: What is the pulse pressure for a patient whose blood pressure is 158/96 mmHg and whose pulse rate is 72 bpm? Question: A 70 year old man has a blood pressure of 150/90 in a lying position, 130/80 in a sitting position, and 100/60 in a standing position. How should the nurse evaluate these findings? Question: The nurse is helping another nurse take a blood pressure reading on a patients thigh. Which action is correct regarding the thigh pressure ? Question: The nurse is preparing to measure the vital signs of a 6 month old infant. which action by the nurse is correct? Question: A 4-month-old child is at the clinic for a well-baby checkup and immunizations. which of these actions is most appropriate when a nurse is assessing the infant’s vital signs? Question: The nurse is conducting a health fair for older adults. which statement is true regarding vital sign measurements in aging adults? Question: In a patient with acromegaly, the nurse will expect to discover which assessment findings? Question: The nurse is performing a general survey of a patient. Which finding is considered normal? Question: The nurse is assessing pediatric children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children? Question: What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap? Question: When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure is best described as which statemen? Question: A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? Question: Which of these specific measurements is the best index of a child’s general health? Question: The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have? Question: The nurse is counting an infant’s respirations. Which technique is correct? Question: When checking for the proper blood pressure cuff size, which guideline is correct? Question: During an examination a nurse notices that a female patient has a round moon face, central trunk obesity and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition? Question: While measuring a patient’s blood pressure, the nurse uses proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply Question: The nurse is testing a patient’s visual accommodation, which refers to which action ? Question: A position tells the nurse that a patients vertebra prominens is tender and ask the nurse to reevaluate the area in one hour period the area of the body the nurse will assess is: Question: Another brings her 2-month-old daughter in for an examination and says my daughter rolled over against the wall, and now I have noticed that she has the spot that is soft on top of her head. Is something terribly wrong? the nurse’s best response would … : Question: The nurse notices that a patient’s palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve? Question: A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: Question: When examining the face of patient, the nurse is aware that the two pairs of salivary glands that are accessible to the examination are the _____ and ______ glands. Question: A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ________ and proceeds with the examination by______. Question: When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the Question: A patient’s laboratory data reveal an elevated t4 level. The nurse would proceed with an examination of the _______ gland. Question: A patient says that she has recently noticed a lump in the front of her neck below her Adam’s apple that seems to … getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not … a cancerous thyroid nodule is that the lump: Question: The nurse notices that patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients Question: The nurse is aware that the four area in the body where lymph nodes are accessible are the: Question: A mother brings her new born in for an assessment and asks, is there something wrong with my baby? His head seems so big. which statement is true regarding the relative proportions of the head and trunk of the newborn? Question: A patient, an 85-year-old woman, is complaining about the fact that her bones in her face have become more noticeable. what explanation should the nurse give her? Question: A patient reports an excruciating headache pain on one side of his head, especially around his eyes, forehead, and cheek that has lasted Approximately 2 hours, occurring once or twice each day period the nurse should suspect: Question: A patient complains that while studying for an examination he began to notice a severe headache and they frontotemporal Area of his head that is throbbing and a somewhat relieved when he lies down. he tells the nurse that his mother also has these headaches. The nurse suspects that he may … suffering from: Question: A 19-year-old college student is brought to the emergency Department with a severe headache he describes as like nothing I’ve ever had before. His temperature is 40 C And he has a stiff neck. The nurse looks for other signs and symptoms of which problem? Question: During a well-baby checkup, the nurse notices that a one-week old infant’s face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and down cast or setting sun eyes. The nurse suspects which condition? Question: The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: Question: A patient has come in for an examination and states, I have the spot in front of my earlobe on my cheek that seems to … getting bigger and is tender. What do you think it is? The nurse notes swelling below the angle of the jaw and suspects that it could … an inflammation of his: Question: A male patient with a history of AIDS has come in for an examination and he states, I think I have the mumps. The nurse would begin by examining the: Question: The nurse suspects that a patient has hyperthyroidism, in the laboratory data indicate that the patients T 4 and T 3 hormone levels or elevated. which of these findings with the nurse most likely find an examination? Question: A visitor from Poland who does not speak English seems to … somewhat apprehensive about the nurse examining his neck. he would probably … more comfortable with the nurse examining his thyroid gland from: Question: A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a _____ sound that is heard best with the _____ of the stethoscope. Question: The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. she states that she noticed the lump approximately 8 hours after her baby’s birth and that it has seem to get bigger. One possible explanation for this is Question: A mother brings in her newborn infant for an assessment and tells the nurse that she has notice that whenever her newborn’s head is turned to the right side she straightens out the arm and leg on the same side and flex is the opposite arm and leg. After observing this an examination call it the nurse tells her that this reflex is: Question: During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: Question: When examining children affected with Down syndrome (trisomy 21) the nurse looks for the possible presence of Question: A patient this is the clinic because he has recently noted that the left side of his mouth is paralyzed. he states that he cannot raise his eyebrow or whistle. the nurse suspects that he has: Question: A woman comes to the clinic and states, I’ve been sick for so long! My eyes have gotten so puffy and my eyebrows and hair have become course and drive. the nurse will assist for other signs and symptoms of: Question: During an examination of a female patient, the nurse notes lymphadenopathy and suspects and acute infection. Acutely infected lymph nodes would … : Question: The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient’s trachea is: Question: During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? Question: The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. these findings are characteristic of: Question: While performing a well child assessment on a 5-year-old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 centimeters in size, round, mobile, and nontender. The nurse suspects that this child: Question: The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes and healthy adults are normally: Question: During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient’s thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient: Question: During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck to described by which statement? Question: During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. which response by the nurse is appropriate? Question: During an examination of a 3-year-old child, the nurse notices a bruit Over the left temporal area. the nurse should: Question: During an examination, the nurse palpates a patients left temporal artery is tortuous and feels hard and tender, compared with the right temporal artery. The nurse suspects which condition? Question: The nurse is assessing a one-month old infant at his well-baby checkup. which assessment findings are appropriate for this age? Select all that apply Question: When examining the eye, the nurse notices that the patient’s eyelid margins approximate completely. The nurse recognizes that this assessment finding: Question: During the ocular examinations, the nurse keeps in mind that movement of the extra ocular muscles is: Question: The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? Question: When examining a patient’s eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: Question: The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? Question: The nurse is conducting a visual examination. which of the statements regarding visual pathways and visual field is true? Question: A mother asks when her newborn infant’s eyesight will … developed. The nurse should reply: Question: The nurse is reviewing age related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? Question: A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should Question: The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? Question: A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: Question: A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? Question: A patient’s vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: Question: When performing the corneal light reflex assessment, the nurse noted that the light is reflected at 2 o’clock in each eye. The nurse should: Question: The nurse is performing the diagnostic positions test. Normal findings would … which of these results? Question: During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? Question: A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? Question: During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? Question: When assessing the pupillary light reflex, the nurse should use which technique? Question: The nurse is assessing a patient size for accommodation response and would expect to see which normal finding? Question: In using the ophthalmoscope to assess a patient eyes, the nurse notices a red glow in the patience pupils. On the basis of this finding, the nurse would: Question: The nurses examining a patient’s retina with an ophthalmoscope. Which finding is considered normal? Question: A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: Question: The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: Question: The nurse is performing an eye screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a lazy eye and should: Question: The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? Question: The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should; Question: When a light is directed across the iris Ave patience I from the temporal side, the nurse is assessing for; Question: In a patient who has anisocoria, the nurse would expect to observe: Question: A patient comes to the emergency Department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cannot see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: Question: A patient comes into the clinic complaining of pain in her right eye. An examination, the nurses at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: Question: A 68-year-old woman is in the eye clinic for an eye checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seen the faces of her grandchildren. On examination the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: Question: A patient comes into the emergency Department after an accident at work period a machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings I would suggest that he has suffered a corneal abrasion? Question: An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: Question: During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency Department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: Question: During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. Be patient complains of his eye feeling dry and itchy. Which action by the nurses correct? During an examination, a patient states that she was diagnosed with open angle glaucoma 2 years ago. The nurse assesses for characteristics of open angle glaucoma. Which of these are characteristics of open angle glaucoma? Select all that apply Question: The primary purpose of the ciliated mucous membrane in the nose is to: Question: The projections in the nasal cavity that increase the surface area are called the : Question: The nurse is reviewing the development of the newborn infant. Regarding the sinuses which statement is true in relation to the newborn infant? Question: The tissue that connects the tongue to the floor of the mouth is the: Question: The salivary gland is the largest and located in the cheek in front of the ear is the ______ gland. Question: In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings Question: The nurses obtaining a health history on a 3-month-old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurse’s best response would … : Question: The nurse is assessing an 80-year-old patient. Which of these findings would … expected for this patient? Question: The nurse is performing an oral assessment on a 40-year-old black patient And notice is the presence of a one centimeter, grayish white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: Question: While obtaining a health history, a patient told the nurse that he has frequent nose bleeds and asks the best way to get them to stop. What would the nurses best response … ? Question: A 92-year-old patient has had a stroke. the right side of his face is drooping. The nurse might also suspect which of these assessment findings? Question: While obtaining a health history from the mother of a one-year old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, it makes a great pacifier. The best response by the nurse would … : Question: A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would … : Question: The nurse is using and otoscope to assess the nasal cavity. Which of these techniques is correct? Question: The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appear pale, grey, and swollen. What would … the most appropriate question to ask the patient? Question: The nurse is palpating the sinus areas. If the findings are normal calmer than the patient should report which sensation? Question: During an oral assessment of a 30-year-old black patient, the nurse notices blueish lips and a dark line along the gingival margin. What action with the nurse perform in response to this finding? Question: During an assessment of a 20-year-old patient with a 3 day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: Question: A 32-year-old woman is at the clinic for little white bumps in her mouth. During the assessment, the nurse notes that she has a 0.5 centimeter white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? Question: A 10-year-old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would … consistent with an acute infection? Question: Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? Question: The nurse notices that the mother of a 2-year-old boy bring him into the clinic quite frequently for various injuries and suspects there may … some child abuse involved. During an inspection of his mouth, the nurse should look for: Question: The nurse is assessing a 3-year-old for drainage from the nose. On assessment, purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. what should the nurse do next? Question: During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lip skin border. The patient mentions that she has just returned from Hawaii. What would … the most appropriate response by the nurse? Question: While performing an assessment of the mouth, the nurse notices that the patient has a one-centimeter ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would … most important for the nurse to assess? Question: A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would an appropriate response … by the nurse? Question: A 40 year old patient who is just finished chemotherapy for breast cancer tell the nurse that she is concerned about her mouth. During the assessment the nurse find areas of the bucal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: Question: The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? Question: The nurse is assessing a patient with a history of IV drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could … an early sign of: Question: A mother brings her 4 month old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since one month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5 centimeter, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is … What would the nurse tell this mother? Question: The mother is concerned because her 18 month old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse’s best response would … : Question: When examining the mouth of an older patient, the nurse recognizes that which finding is due to the aging process? Question: When assessing the nares of a 45 year old patient who has complaints of rhinorrhea, itching of the nose and eyes and sneezing the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these is the likely cause? Question: When assessing the tongue of an adult, the nurse knows that an abnormal finding would … Question: The nurse is performing an assessment. Which of these findings would cause the greatest concern? Question: A patient has been … with strep throat. The nurse is aware that without treatment, which complication may occur? Question: During a checkup, a 22-year-old woman tells the nurse that she uses an over the counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would … : Question: A 65 year old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate? Question: During the oral examination of a 4-year-old Native American child, the nurse notices that her uvula is partially split. Which of these statements is true? Question: A patient comes into the clinic complaining official pain, fever, and malaise. An examination, the nurse notes swollen turbinates and prevent discharge from the nose. Be patient also complained of a dull, throbbing pain in his cheeks and teeth on the right side in pain when the nurse palpates the areas. the nurse recognizes that this patient has: Question: A woman who is in the second trimester of pregnancy mentions that she has had more nose bleeds and then ever since she became pregnant. The nurse recognizes that this is a result of: Question: The nurse is teaching a health class too high school boys. When discussing the topic of using smokeless tobacco which of these statements are accurate. Select all that apply. Question: During an assessment, a patient mentions that I just can’t smell like I used to. I can barely smell the roses in my garden. Why is that? For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. Question: The nurse needs to pull the portion of the ear that contains movable cartilage and skin down and back when administering airdrops. the portion of this here is called the: Question: The nurses examining a patient ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? Question: When examining an ear with an otoscope, the nurse notes that the tympanic membrane should appear: Question: The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? Question: A patient with a middle ear infection asks the nurse, what does the middle ear do? The nurse responds by telling the patient that the middle ear functions to: Question: The nurse is reviewing the function of cranial nerves. Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? Question: The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? Question: A patient has been … to have sensorineural hearing loss. During the assessment, it would … important for the nurse to: Question: During an interview, the patient states that he has the sensation that everything around him is spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the: Question: A patient in her first trimester of pregnancy is … with rubella. Which of these statements is correct regarding the significance of this in relation to the infants hearing? Question: The mother of a 2 year old is concerned because her son has had three ear infections in the past year. What would … an appropriate response by the nurse? Question: And 31 year old patient tells the nurse said he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: Question: Is 70 year old patient tells the nurse that he has noticed he is having trouble hearing, especially in large groups. He says that he can’t always tell where the sound is coming from and the words often sound mixed up. What might … nurse suspect as the cause for this change? Question: During the assessment of a 20 year old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: Question: The nurse is taking the history of a patient who may have a perforated eardrum. what would … an important question in this situation? Question: A 31-year-old patient tells the nurse that has notice pain in his left ear when people speak loudly to him. The nurse knows that this finding: Question: While discussing the history of a 6 month old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would … nurse want to include in the history? Question: The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? Question: The nurse is assessing a 16 year old patient who has suffered head injuries from a recent motor vehicle accident. Which of the statements indicates the most important reason for assessing any drainage from the ear canal? Question: In performing a voice test to assess hearing, which of these actions with the nurse perform? Question: In performing an examination of a 3 year old child with a suspected ear infection, the nurse would: Question: The nurse is preparing to perform on otoscopic examination of a newborn infant. Which statement is true regarding this examination Question: The nurse asses the hearing of a 7 month old infant by clapping hands. What is the … response? The infant: Question: The nurse is performing an ear examination of an 80 year old patient. which of these findings would … considered normal ? Question: An assessment of a 23 year old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? Question: While performing the otoscopic examination of a 3 year old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The nurse interprets these findings to indicate a(n): Question: The mother of a 2 year old toddler is concerned about the upcoming tympanostomy tubes in her sons ears. The nurse would include which of these statements in the teaching plan? Question: In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? Question: When performing an otoscopic examination of a 5 year old child with a history of chronic ear infections, dinner sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child: Question: The nurse is performing an assessment on a 65 year old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: Question: The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? Question: The nurse is performing a middle ear assessment on a 15 year old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse is the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly white with the light reflex at 5 o’clock and landmarks visible. The nurse should: Question: The nurse is preparing to do an otoscopic examination on a 2 year old child. Which one of these reflects the correct procedure? Question: The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections? Question: During an otoscopic examination the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest? Question: A 17 year old student is a swimmer on her high school’s swim ear. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to: Question: During an examination, the patient states he is hearing a buzzing sound and says that it is driving me crazy! The nurse recognized that this symptom indicates: Question: During an examination, the nurse notices that the patient stumbles a little while walking and when she sits down she holds on to the side of the chair. The patient states, it feels like the room is spinning. The nurse notices that the patient is experiencing: Question: A patient has been … after an accident at work. During the assessment , the patient is having trouble hearing and states, I don’t know what the matter is. All of a sudden, I can’t hear you out of my left ear. What should the nurse do next? Question: The nurse is testing the hearing of a 78 year old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply. Question: Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: Question: When performing a respiratory assessment on a patient, the nurse notices costal angle of approximately 90 degrees. This characteristic is Question: When assessing the patient’s lungs, the nurse recalls that the left lung: Question: Which statement about the apices of the lungs is true? The apices of the lungs are: Question: During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: Question: During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of : Question: The primary muscles of respiration include the: Question: A patient has been … to the emergency Department for … drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? Question: When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? Question: The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus. Tactile fremitus: Question: During percussion the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: Question: The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. Question: When auscultating the lungs of an adult patient, the nurse notes that low pitched, soft breath sounds or … over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: Question: The nurse is auscultating the chest in an adult. Which technique is correct? Question: The nurse is percussing over the lungs of a patient with pneumonia. The nurse knowns that percussion over an area of atelectasis in the lungs will reveal: Question: During auscultation of the lungs, the nurse expects decreased breath sounds to … heard in which situation? Question: The nurse knows that a normal finding when assessing the respiratory system of an older adult is: Question: A mother brings her 3 month old infant to the clinic for evaluation of a cold. She told the nurse that he has had a runny nose for a week period. The nurses next action should … to: Question: When assessing the respiratory system of a 4 year old child, which of these findings with the nurse expect? Question: When inspecting the anterior chest of an adult, the nurse should include which assessment? Question: During an assessment of an adult, the nurse has noticed unequal chest expansion an recognizes that this occurs in which situation: Question: The nurse knows that auscultation of fine crackles would most likely … noticed in: Question: during auscultation of the lungs as an adult patient comma the nurse notices the presence of bronchoscopy. The nurse should assess for signs of which condition? Question: The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sound is true? Question: The nurse is listening to breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles Would produce which of these adventitious sounds? Question: A patient has a long history of chronic obstructive pulmonary disease. During the assessment the nurse will likely observe which of these? Question: In teenage patient comes to the emergency Department with complaints of inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, Tracheal deviation to the right, decreased tactile fremitus on the left, hyper resonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: Question: An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: Question: The nurse is assessing the lungs of an older adults. Which of these changes are normal in the respiratory system of that older adult? Question: A woman in her 26th week of pregnancy states that she is not really short of breath but feels that she is aware of her breathing in the mean to breathe. What is the nurses best reply? Question: A 35 year old recent immigrant is being … in the clinic for complaints of a cough that is … with rust colored sputum, low grade afternoon fevers, and night sweats for the past 2 months. The nurse’s preliminary analysis based on this history is that the patient may be suffering from: Question: A 70 year old patient is being … in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? Question: A patient comes to the clinic complaining of a call that is worse at night but not as bad during the day. But this cough may indicate: Question: During a morning assessment, the nurse notices that a patient’s sputum is frothy and pink. Which condition could this finding indicate? Question: During auscultation of breath sounds call the nurse should correctly use the stethoscope in which of the following ways? Question: A patient has been … to the emergency Department with a possible medical … of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? Question: During palpation of the interior chest wall, the nurse notices a course, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: Question: The nurses auscultating the lungs of a patient who has been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: Question: A patient with pleuritis has been … to the hospital and complained of pain with breathing. What other key assessment finding with the nurse expect to find upon auscultation ? Question: The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicate a normal assessment? Select all that apply.