While taking a history, the nurse observes that the patient's facial cranial nerves (CN
VII) are intact based on which behaviors of the patient?
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Option C represents facial symmetry, which is controlled by the facial
cranial nerve (CN VII). Option A represents movement of the extraocular
muscles, which are controlled by the oculomotor, trochlear, and abducens
cranial nerves (CN III, IV, and VI, respectively). Option B represents
movement of the tongue, which is controlled by the hypoglossal cranial
nerve (CN XII). Option D represents function of the oculomotor cranial
nerve (CN III).
, c. The sides of the mouth are symmetric when the patient smiles.
Which finding warrants a referral for additional evaluation?
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The pinna of the ear should align directly with the outer canthus of the eye
and be angled no more than 10 degrees from a vertical position. Earlobes
hanging freely from the base of the pinna is an expected finding. Option B
is called a Darwin tubercle. It is a normal deviation and may be noted at the
helix of the ear. A length of 8 cm is an expected finding.
The nurse is interviewing a woman with her husband present. The husband answers
the questions for the wife most of the time. What is the most appropriate therapeutic
nursing action to hear the patient's viewpoint?
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Asking the husband to step out of the room will allow the patient to answer
questions in her own way. Continuing the interview is not a therapeutic
action because the nurse needs to obtain the patient's answers to the
questions. Asking another nurse to complete the interview does not solve
the problem that the husband is answering questions for his wife. Telling the
woman to speak up for herself does not solve the problem and may
interfere with the therapeutic relationship between the patient and the
nurse.
How does a nurse recognize normal accommodation?
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, Option D is an indication of accommodation. Normally a patient has 90
degrees peripheral vision temporally, but only 60 degrees nasally. Option A
is an expected finding, but is not a test for accommodation. Option B is a
test of extraocular muscle function in the six cardinal fields of gaze. Option
C is an expected finding for consensual reaction, rather than
accommodation.
d. The patient's pupils dilate when looking toward a distant object.
What technique does a nurse use when palpating the right lobe of a patient's thyroid
gland using the anterior approach?
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b. Displaces the trachea to the right with the left thumb
Option B is the correct technique for palpating the thyroid gland using the
anterior approach. Options A, C, and D are not correct techniques.
A nurse uses which technique to assess a patient's peripheral vision?
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Option C is the confrontation test that tests peripheral vision. Option A
tests extraocular muscle symmetry. The cover-uncover technique is
performed when the corneal light reflex is asymmetric. Option D describes
the corneal light reflex that tests the symmetry of the eye muscles.
What is the best action for a nurse should take after auscultating a BP of 128/70 on an
older adult client?
, Give this one a try later!
document findings
Which question is an example of an open-ended question?
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"What were you doing when you felt the pain?" is a broadly stated question
that encourages a free-flowing, open response. "Have you experienced this
pain before?" is closed-ended, which can obtain a "yes" or "no" answer to
the question without any additional data. "Do you have someone to help
you at home?" is closed-ended, which can obtain a "yes" or "no" answer to
the question without any additional data. "How many times a day do you
use your inhaler?" is closed-ended, which can obtain an answer of a
specific number without any additional data.
What instructions does the nurse give the patient before using the Snellen visual
acuity chart?
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c. "Hold a white card over one eye and read the smallest possible line."
Option C is the appropriate technique for using the Snellen chart. Patients
should wear their glasses when visual acuity is tested. The patient should
stand 20 feet from the Snellen chart. The patient should not squint to see
the chart.
The neural and vascular control of core body temperature is regulated by the ________
VII) are intact based on which behaviors of the patient?
Give this one a try later!
Option C represents facial symmetry, which is controlled by the facial
cranial nerve (CN VII). Option A represents movement of the extraocular
muscles, which are controlled by the oculomotor, trochlear, and abducens
cranial nerves (CN III, IV, and VI, respectively). Option B represents
movement of the tongue, which is controlled by the hypoglossal cranial
nerve (CN XII). Option D represents function of the oculomotor cranial
nerve (CN III).
, c. The sides of the mouth are symmetric when the patient smiles.
Which finding warrants a referral for additional evaluation?
Give this one a try later!
The pinna of the ear should align directly with the outer canthus of the eye
and be angled no more than 10 degrees from a vertical position. Earlobes
hanging freely from the base of the pinna is an expected finding. Option B
is called a Darwin tubercle. It is a normal deviation and may be noted at the
helix of the ear. A length of 8 cm is an expected finding.
The nurse is interviewing a woman with her husband present. The husband answers
the questions for the wife most of the time. What is the most appropriate therapeutic
nursing action to hear the patient's viewpoint?
Give this one a try later!
Asking the husband to step out of the room will allow the patient to answer
questions in her own way. Continuing the interview is not a therapeutic
action because the nurse needs to obtain the patient's answers to the
questions. Asking another nurse to complete the interview does not solve
the problem that the husband is answering questions for his wife. Telling the
woman to speak up for herself does not solve the problem and may
interfere with the therapeutic relationship between the patient and the
nurse.
How does a nurse recognize normal accommodation?
Give this one a try later!
, Option D is an indication of accommodation. Normally a patient has 90
degrees peripheral vision temporally, but only 60 degrees nasally. Option A
is an expected finding, but is not a test for accommodation. Option B is a
test of extraocular muscle function in the six cardinal fields of gaze. Option
C is an expected finding for consensual reaction, rather than
accommodation.
d. The patient's pupils dilate when looking toward a distant object.
What technique does a nurse use when palpating the right lobe of a patient's thyroid
gland using the anterior approach?
Give this one a try later!
b. Displaces the trachea to the right with the left thumb
Option B is the correct technique for palpating the thyroid gland using the
anterior approach. Options A, C, and D are not correct techniques.
A nurse uses which technique to assess a patient's peripheral vision?
Give this one a try later!
Option C is the confrontation test that tests peripheral vision. Option A
tests extraocular muscle symmetry. The cover-uncover technique is
performed when the corneal light reflex is asymmetric. Option D describes
the corneal light reflex that tests the symmetry of the eye muscles.
What is the best action for a nurse should take after auscultating a BP of 128/70 on an
older adult client?
, Give this one a try later!
document findings
Which question is an example of an open-ended question?
Give this one a try later!
"What were you doing when you felt the pain?" is a broadly stated question
that encourages a free-flowing, open response. "Have you experienced this
pain before?" is closed-ended, which can obtain a "yes" or "no" answer to
the question without any additional data. "Do you have someone to help
you at home?" is closed-ended, which can obtain a "yes" or "no" answer to
the question without any additional data. "How many times a day do you
use your inhaler?" is closed-ended, which can obtain an answer of a
specific number without any additional data.
What instructions does the nurse give the patient before using the Snellen visual
acuity chart?
Give this one a try later!
c. "Hold a white card over one eye and read the smallest possible line."
Option C is the appropriate technique for using the Snellen chart. Patients
should wear their glasses when visual acuity is tested. The patient should
stand 20 feet from the Snellen chart. The patient should not squint to see
the chart.
The neural and vascular control of core body temperature is regulated by the ________
