NUR101/ NUR 101(Latest 2024/ 2025 Update) Health Assessment | Practice Questions and Verified Answers| 100% Correct| Grade A – Fortis

NUR101/ NUR 101(Latest 2024/ 2025 Update) Health Assessment | Prac tice Questions and Verified Answers| 100% Correct| Grade A – Fortis Q: The nurse is palpating the temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the tragus. Which of the following would be a normal finding? A) Nontender to palpation B) Crepitus C) The jaw locking D) Painful palpation Answer: The correct answer is A: Nontender to palpation. When palpating the TMJ normal findings are smooth movement with no popping, crepitus, or tenderness. Q: Which of the following subjective data would you want to collect for your patient when performing a Head, Face and Neck Exam? (Select all that apply) A. they have unusually frequent or severe headaches B. If they have any dizziness C. If they have any neck pain D. If they have any chest pain E. If they have any history of neck injury or surgery Answer: Correct answers are A, B, C, E. Subjective data that you want to collect includes: Headache History of head injury, cosmetic or cranial surgery Dizziness Neck pain Noticed lumps or swelling History of neck injury or surgery Q: 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. A)Low gurgling; bell B) Loud, whooshing, blowing; diaphragm C) Soft, whooshing, pulsatile; bell D)High -pitched tinkling; diaphragm Answer: Correct answer is C: a bruit is a soft, whooshing, pulsatile sound that is best assessed with the bell of the stethescope. Q: The nurse is assessing the patient's trachea. Which of the following would be a normal finding? A.The trachea rising to midline when the patient swallows B.The trachea deviating to the left when the person swallows C.The trachea deviating to the right when the person swallows D.The trachea not moving when the person swallows Answer: Correct answer is A. The trachea should rise to the midline when the patient swallows. If it deviates to one side or the other that can indicate stroke or tumor. Q: The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check the extraocular eye muscles. The nurse knows that a healthy finding would be: A. Each eye moves in opposite directions from each other B. There is parallel tracking of the object with both eyes. C. A rapid eye blink is expected. D. The light reflex of the eyes is located in the same position in each eye. Answer: Correct Answer: B A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it. Q: When assessing the pupillary light reflex, the nurse should use which technique? A) Shine a penlight from directly in front of the patient and inspect for pupillary constriction. B) Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. C) Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. D) Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose. Answer: Correct Answer: C To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction. Q: When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: A) consider this a normal finding. B) refer the individual for further evaluation. C) document this as an asymmetric light reflex. D) perform the confrontation test to validate the findings. Answer: Correct Answer: A Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test. Q: The nurse is assessing the pupils of a patient with a pen light. Which finding would be considered normal? A)Both eyes cross when exposed to the light. B)The patient's pupils are fixed and dilated in response to light. C)Both pupils dilate in response to light. D)Both pupils constrict in response to light. Answer: Correct Answer: D The pupils should constrict in response to light. Q: In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: A) suspect that there is an opacity in the lens or cornea. B) check the light source of the ophthalmoscope to verify that it is functioning. C) consider this a normal reflection of the ophthalmoscope light off the inner retina. D) continue with the ophthalmoscopic examination and refer the patient for further evaluation. Answer: Correct Answer: C The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct. Q: The nurse is charting on a patient's eye assessment and notes PERRLA. What does this stand for? A. Pupils Equal, Rigid, React to Light, and Accessible B. Pupils Even, Right, React to Light, and Accomodation C. Pupils Equal, Round, React to Light and Accomodation D. Pupils Even, Rigid, Restrict from Light, and Accomodation Answer: The correct answer is C Pupils Equal, Round, React to Light, and Accommodation Q: During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: A) decreased in the elderly. B) impaired in a patient with cataracts.