Health assessment review Latest
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,The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes.
The nurse should implement which assessment technique to assess for muscle weakness in the eye? -
correct ans:Test the 6 cardinal positions of gaze.
Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness
in the eyes. The client is asked to hold the head steady, and then to follow movement of an object
through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes.
The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should
explain that which is the best time to perform this exam? - correct ans:After a shower or bath
The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to
perform the exam on the same day each month. The nurse should also instruct the client that the best
time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is
warm.
What is Brudzinski's sign? - correct ans:pain w/ passive neck flexion
sign of meningeal irritation
The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a
positive Brudzinski's sign. Which finding did the nurse observe? - correct ans:The client passively flexes
the hip and knee in response to neck flexion and reports pain in the vertebral column.
The community health nurse is instructing a group of young female clients about breast self-
examination. The nurse should instruct the clients to perform the examination at which time? - correct
ans:One week after menstruation begins
The breast self-examination should be performed regularly, 7 days after the onset of the menstrual
period. Performing the examination weekly is not recommended. At the onset of menstruation and
during ovulation, hormonal changes occur that may alter breast tissue.
The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the
accurate procedure for this visual acuity test? - correct ans:The right eye is tested, followed by the left
eye, and then both eyes are tested.
,Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably
standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the
right eye covered. Both eyes are then tested together. Visual acuity is measured with or without
corrective lenses, and the client stands at a distantof 20 feet (6 meters) from the chart.
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What
action should the nurse implement based on this finding? - correct ans:Instruct the client that he or she
may need glasses when driving.
Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person
with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read
at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters).
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should
expect to note which finding? - correct ans:Waves of loud gurgles auscultated in all 4 quadrants
Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal
bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate
hyperperistalsis and are commonly associated with nausea and vomiting.
A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to
use in obtaining the client's health history? - correct ans:Plan short sessions with the client to obtain
data.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of
the client, the nurse should expect to note which findin - correct ans:Rhythmic respirations with periods
of apnea
A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing
problem. The nurse plans to explain to the client that this condition is caused by which problem? -
correct ans:A physical obstruction to the transmission of sound waves
, A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound
waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect
in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse
auscultates a murmur. The nurse documents the finding and describes the sound as which? - correct
ans:A blowing or swooshing noise
The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The
appropriate instruction regarding when the BSE should be performed is at which time? - correct ans:At a
specific day of the month and on that same day every month thereafter
If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the
same day every month. Options that recommend scheduling related to menses are inappropriate
because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE
at ovulation time because of the hormonal changes that occur.
The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment
on a client. Which statement by the new RN indicates that the teaching has been effective? - correct
ans:This is mostly used in a walk-in clinic or emergency department."
The community health nurse who is conducting a teaching session about the risks of testicular cancer
has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending
the session. Which statement by a client indicates a need for further instruction? - correct ans:"It is best
to do TSE first thing in the morning before a bath or shower."
The nurse is preparing to perform an abdominal examination on a client. The nurse should place the
client in which position for this examination? - correct ans:Supine with the head raised slightly and the
knees slightly flexed
The nurse has obtained a personal and family history from a client with a neurological disorder. Which
factors in the client's history are associated with added risk for neurological problems? Select all that
apply. - correct ans:2.History of headaches 3.Previous back injury 4.History of hypertension
Verified Version And Frequently tested
Exam With Expected real Questions
With Well Elaborated Correct Answers
GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
,The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes.
The nurse should implement which assessment technique to assess for muscle weakness in the eye? -
correct ans:Test the 6 cardinal positions of gaze.
Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness
in the eyes. The client is asked to hold the head steady, and then to follow movement of an object
through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes.
The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should
explain that which is the best time to perform this exam? - correct ans:After a shower or bath
The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to
perform the exam on the same day each month. The nurse should also instruct the client that the best
time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is
warm.
What is Brudzinski's sign? - correct ans:pain w/ passive neck flexion
sign of meningeal irritation
The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a
positive Brudzinski's sign. Which finding did the nurse observe? - correct ans:The client passively flexes
the hip and knee in response to neck flexion and reports pain in the vertebral column.
The community health nurse is instructing a group of young female clients about breast self-
examination. The nurse should instruct the clients to perform the examination at which time? - correct
ans:One week after menstruation begins
The breast self-examination should be performed regularly, 7 days after the onset of the menstrual
period. Performing the examination weekly is not recommended. At the onset of menstruation and
during ovulation, hormonal changes occur that may alter breast tissue.
The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the
accurate procedure for this visual acuity test? - correct ans:The right eye is tested, followed by the left
eye, and then both eyes are tested.
,Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably
standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the
right eye covered. Both eyes are then tested together. Visual acuity is measured with or without
corrective lenses, and the client stands at a distantof 20 feet (6 meters) from the chart.
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What
action should the nurse implement based on this finding? - correct ans:Instruct the client that he or she
may need glasses when driving.
Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person
with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read
at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters).
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should
expect to note which finding? - correct ans:Waves of loud gurgles auscultated in all 4 quadrants
Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal
bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate
hyperperistalsis and are commonly associated with nausea and vomiting.
A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to
use in obtaining the client's health history? - correct ans:Plan short sessions with the client to obtain
data.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of
the client, the nurse should expect to note which findin - correct ans:Rhythmic respirations with periods
of apnea
A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing
problem. The nurse plans to explain to the client that this condition is caused by which problem? -
correct ans:A physical obstruction to the transmission of sound waves
, A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound
waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect
in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse
auscultates a murmur. The nurse documents the finding and describes the sound as which? - correct
ans:A blowing or swooshing noise
The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The
appropriate instruction regarding when the BSE should be performed is at which time? - correct ans:At a
specific day of the month and on that same day every month thereafter
If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the
same day every month. Options that recommend scheduling related to menses are inappropriate
because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE
at ovulation time because of the hormonal changes that occur.
The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment
on a client. Which statement by the new RN indicates that the teaching has been effective? - correct
ans:This is mostly used in a walk-in clinic or emergency department."
The community health nurse who is conducting a teaching session about the risks of testicular cancer
has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending
the session. Which statement by a client indicates a need for further instruction? - correct ans:"It is best
to do TSE first thing in the morning before a bath or shower."
The nurse is preparing to perform an abdominal examination on a client. The nurse should place the
client in which position for this examination? - correct ans:Supine with the head raised slightly and the
knees slightly flexed
The nurse has obtained a personal and family history from a client with a neurological disorder. Which
factors in the client's history are associated with added risk for neurological problems? Select all that
apply. - correct ans:2.History of headaches 3.Previous back injury 4.History of hypertension
