NR 509 Week 2 Advanced Health Assessment Exam Questions & Answers (Updated 2025, Graded A+)

NR 509 WEEK 2 EXAM QUESTIONS UPDATED 100% CORRECT ANSWERS ALREADY GRADED A+ [REVISED] 1. When performing a physical assessment, the first technique the nurse will always use A. Palpation B. Inspection C. Percussion D. Auscultation: B. Inspection 2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: A. Usually yields little information B. Takes time and reveals a surprising amount of information C. May be somewhat uncomfortable for the expert practitioner D. Requires a quick glance at the patient's body systems before proceeding with palpation: B. Takes time and reveals a surprising amount of information 3. The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature? A. Fingertips; they are more sensitive to small changes in temperature B. Dorsal surface of the hand; the skin is thinner on this surface than on the palms C. Ulnar portion of the hand, increased blood supply in this area enhances temperature sensitivity D. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.: B. Dorsal surface of the hand; the skin is thinner on this surface than on the palms 4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? A. Palpation B. Inspection C. Percussion D. Auscultation: A. Palpation 5. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? A. Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain B. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience C. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. D. The assessment begins with light palpation to detect surface characteris- tics and to accustom the patient to being touched.: D. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched. 6. The nurse would use bimanual palpation technique in which situation? A. Palpating the thorax of an infant B. Palpating the kidneys and the uterus C. Assessing pulsations and vibrations D. Assessing the presence of tenderness and pain: B. Palpating the kidneys and the uterus 7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. A. Turgor B. Texture C. Density D. Consistency: C. Density 8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? A. Percussing once over each area B. Quickly lifting be striking finger after each stroke C. Striking with the fingertip, not the finger pad D. Using the wrist to make the strikes, not the arm: A. Percussing once over each area 9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: A. Consider this a normal finding B. Palpate this area for an underlying mass C. Reposition the hands, and attempt to percuss in this area again D. Consider this finding abnormal, and refer the patient for additional treat- ment: A. Consider this a normal finding 10. 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? A. Ask the patient to take deep breaths to relax the abdominal musculature B. Consider this finding as normal and proceed with the abdominal assess- ment C. Increase the amount of strength used when attempting to percuss over the abdomen D. Decrease the amount of strength used when attempting to percuss over the abdomen.: C. Increase the amount of strength used when attempting to percuss over the abdomen 11. The nurse hears bilateral loud, long and low tones when percussing over the lungs of a 4 year old child. The nurse should A. Palpate over the area for increased pain and tenderness B. Ask the child to take shallow breaths and percuss over the area again C. Immediately refer the child because of an increased amount of air in the lungs D. Consider this finding as normal for a child this age and proceed with the examination: D. Consider this finding as normal for a child this age and proceed with the examination 12. A patient has suddenly developed shortness of breath and appears to be 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? A. Count the patient's respirations B. Bilaterally percuss the thorax, noting any differences in percussion tones C. Call for a chest x-ray study and wait for the results before beginning an assessment D. Inspect the thorax for any new masses and bleeding associated with respirations: B. Bilaterally percuss the thorax, noting any differences in percussion tones 13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? A. Slope of the earpieces should point posteriorly (toward to occiput) B. Although the stethoscope does not magnify sound, it does block out extraneous room noise C. Fit and quality of the stethoscope are not as important as its ability to magnify sound D. Ideal tubing length should be 22 inches to dampen the distortion of sound- : B. Although the stethoscope does not magnify sound, it does block out extraneous room noise 14. The nurse is preparing to use a stethoscope for auscultation. Which state- ment is true regarding the diaphragm of the stethoscope? The diaphragm: A. Is used to listen for high-pitched sounds B. Is used to listen for low-pitched sounds C. Should be lightly held against the persons skin to block out low-pitched sounds D. Should be lightly held again the person skin to listen for extra heart sounds and murmurs: A. Is used to listen for high-pitched sounds 15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: A. Warm the endpiece of the stethoscope by placing it in warm water B. Leave the gown on the patient to ensure that she or he does not get chilled during the examination C. Ensure that the bell side of the stethoscope is turned to the on position D. Check the temperature of the room and offer blankets to the patient if she or he feels cold.: D. Check the temperature of the room and offer blankets to the patient if she or he feels cold. 16. The nurse will use which technique of assessment to determine the pres- ence of crepitus, swelling and pulsations? A. Palpation B. Inspection C. Percussion D. Auscultation: A. Palpation 17. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: A. Is often used to direct light onto the sinuses B. Uses a short, broad speculum to help visualize the ear C. Is used to examine the structures of the internal ear D. Directs light into the ear canal and onto the tympanic membrane: D. Directs light into the ear canal and onto the tympanic membrane 18. 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 indicate that the examination is being correctly performed? A. Using the large full circle of light when assessing pupils that are not dilated B. Rotating the lens selector dial to the black numbers to compensate for astigmatism C. Using the grid on the lens aperture to visualize the external structures of the eye D. Rotating the lens selector dial to bring the object into focus: D. Rotating the lens selector dial to bring the object into focus 19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: A. Auscultate over the area with a fetoscope B. Use a goniometer to measure the pulsations C. Use a Doppler device to check for pulsations over the area D. Check for the presence of pulsations with a stethoscope: C. Use a Doppler device to check for pulsations over the area 20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: A. Performs the examination from the left side of the bed B. Examines the tender of painful areas first to help relieve the patient's anxiety C. Follows the same examination sequence, regardless of the patients age or condition D. Organizes the assessment to ensure that the patient does not change positions too often: D. Organizes the assessment to ensure that the patient does not change positions too often 21. 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? A. Appear unhurried and confident when examining him B. Stay in the room when he undresses in case he needs assistance C. Ask him to change into an examination gown to take off his undergarments D. Defer measuring vital signs until the end of the examination which allows him time to become comfortable: A. Appear unhurried and confident when exam- ining him 22. When performing a physical examination, safety must be 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 ? A. Washing one's hands after removing gloves is not necessary, as long as the gloves are still intact B. Hands are washed before and after every physical patient encounter C. Hands are washed before the examination of each body system to prevent the spirit of bacteria from one part of the body to another D. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious disease: B. Hands are washed before and after every physical patient encounter 23. The nurses examining a patient lower leg and notices a training ulceration. Which of these actions is most appropriate in this situation? A. Washing hands and contacting the physician B. Continuing to examine the ulceration, and then washing hands C. Washing hands, putting on gloves, and continuing with the examination of the ulceration D. Washing hands, proceeding with the rest of the physical examination, and then continuing with the examination of the leg ulceration: C. Washig hands, putting on gloves, and continuing with the examination of the ulceration 24. 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? A. Your atrial dysrhythmias are under control B. You have pitting edema and mild varicosities C. Your pulse is 80 beats per minute which is within the normal range D. I am using my stethoscope to listen for any crackles, wheezes or rubs: C. Your pulse is 80 beats per minute which is within the normal range 25. The nurse keeps in mind that the most important reason to share informa- tion and to offer brief teaching while performing be physical examination is to help the: A. Examiner feel more comfortable and to gain control of the situation B. Examiner to build rapport and to increase patient's confidence in him or her C. Patient understand his or her disease process and treatment modalities D. Patient identify questions about his or her disease and the potential areas of patient education: B. Examiner to build rapport and to increase patient's confi- dence in him or her 26. The nurses examining an infant and prepares to elicit the Moro reflex at which time during the examination? A. When the infant is sleeping B. At the end of the examination C. Before auscultation of the thorax D. Halfway through the examination: B. At the end of the examination 27. When preparing to perform a physical examination of the infant, the nurse should: A. Have the parent remove all clothing except the diaper on a boy. B. Instructed the parent to feed the infant immediately before the examination C. Encourage the infant to suck on a pacifier during the abdominal examina- tion D. Ask the parents to leave the room briefly when assessing be infants' vital signs: A. Have the parent remove all clothing except the diaper on a boy. 28. A 6-month-old infant has been brought to the well child clinic for a checkup. she is currently sleeping. What should the nurse do first when beginning the examination? A. Auscultate the lungs and heart while the infant is sleeping B. Examine the instance hips, because this procedure is uncomfortable C. Begin with the assessment of the eye, and continue with the remainder of the examination in a head to toe approach D. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems: A. Auscultate the lungs and heart while the infant is sleeping 29. A 2-year-old child has been brought to the clinic for a well child checkup. the best way for the nurse to begin the assessment is to: A. Ask the parent to place the child on the examining table B. Happy parents remove all of the child's clothing before the examination C. Allow the child to keep a security object such as a toy or blanket during the examination D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained: C. Allow the child to keep a security object such as a toy or blanket during the examination 30. 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 A. Asking questions enhances the child autonomy B. Asking the child for permission helps develop a sense of trust C. This question is inappropriate statement because children at this age like to have choices D. Children at this age like to say no. the examiner should not offer a choice when no choice is available: D. Children at this age like to say no. the examiner should not offer a choice when no choice is available 31. With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on a pen light? A. Infant B. Preschool child C. School age child D. Adolescent: B. Preschool child 32. The nurse is preparing to examine a 4-year-old child. which action is appropriate for this age group? A. Explain the procedures in detail to alleviate the child anxiety B. Give the child feedback and reassurance during the examination C. Do not ask the child to remove his or her clothes because children at this age are usually very private D. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen: B. Give the child feedback and reassurance during the examination 33. When examining a 16-year-old male teenager, the nurse should: A. Discuss health teaching with the parent because the team is unlikely to be interested in promoting wellness B. Ask his parents to stay in the room during the history and physical exami- nation to answer any questions and to alleviate his anxiety C. Talk to him the same manner as one would talk to a younger child because 18 level of understanding may not match his or her speech D. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development: D. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development 34. When examining an older adult, the nurse should use which technique? A. Avoid touching the patient too much B. Attempt to perform the entire physical examination during one visit C. Speak loudly and slowly because most aging adults have hearing deficits D. The range the sequence of the examination to allow as few position changes as possible: D. The range the sequence of the examination to allow as few position changes as possible 35. The most important step that the nurse can take to prevent the transmis- sion of microorganisms in the hospital setting is too: A. Wear protective eyewear at all times B. Wear gloves during any and all contact with patients C. Wash hands before and after contact with each patient D. Clean the stethoscope with an alcohol swab between patients: C. Wash hands before and after contact with each patient 36. Which of the statements is true regarding the use of standard precautions in the health care setting? A. Standard precautions apply to all body fluids, including sweat B. Use alcohol-based hand rub is the hands are visibly dirty C. Standard precautions are intended for use with all patients, regardless of their risk or presumed infection status D. Standard precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucus membranes is pre- sent: C. Standard precautions are intended for use with all patients, regardless of their risk or presumed infection status 37. The nurse is preparing to assess a hospitalized patient who is experienc- ing significant shortness of breath. How should the nurse proceed with the assessment? A. Be patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment B. A thorough history and physical assessment information should be ob- tained from the patient's family member C. A complete history and physical assessment should be immediately per- formed to obtain baseline information D. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved: D. Body areas appropri- ate to the problem should be examined and then the assessment completed after the problem has resolved 38. When examining an instant, the nurse should examine which area first? A. Ear B. Nose C. Throat D. Abdomen: D. Abdomen 39. While auscultating heart sounds, the nurse here is a murmur. Which of these instruments should be used to assess this murmur? A. Electrocardiogram B. Bell of the stethoscope C. Diaphragm of the stethoscope D. Palpation with the nurse is palm of the hand: B. Bell of the stethoscope 40. 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: A. Constipation B. Air filled areas C. Presence of a tumor D. Presence of dense organs: B. Air filled areas 41. The nurse is preparing to examine a 6-year-old child. which action is the most appropriate? A. The thorax, abdomen, and genitalia are examined before the head B. Talking about the equipment being used is avoided because doing so may increase the child anxiety C. The nurse should keep in mind that a child at this age will have a sense of modesty D. The child is asked to undress from the waist up: C. The nurse should keep in mind that a child at this age will have a sense of modesty 42. During auscultation of a patient's heart sounds, the nurse here's an unfa- miliar sound. the nurse should: A. Document the findings in the patients record B. Wait 10 minutes, and auscultate the sound again C. Ask the patient hell he or she is feeling D. Ask another nurse to double check the finding: D. Ask another nurse to double check the finding 43. 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 A. Warm the hands before touching be patient B. For deep palpation, use one long continuous palpation when assessing the liver C. Start with light palpation to detect surface characteristics D. Use the fingertip to examine skin texture, swelling, pulsation, and presence of lumps E. Identify any tender areas and palpate them last F. Use the palms of the hands to assess temperature of the skin: Answer A,C,D,E 44. The nurse is performing a general survey period which action is a compo- nent of the general survey? A. Observing the patient's body stature and nutritional status B. Interpreting the subjective information, the patient has reported C. Measuring the patient's temperature, pulse, respirations, and blood pres- sure D. Observing specific body systems while performing the physical assess- ment: A. Observing the patient's body stature and nutritional status 45. When measuring a patients wait, the nurse is aware of which of these guidelines? A. Be patient is always weighed wearing only his or her undergarments B. The type of scale does not matter, as long as the weights are similar from day to day C. Be patient may leave on his or her jacket and shoes as long as these are documented next to the weight D. In temp should be made to weigh the patient at approximately the same time of day, if a sequence of weight is necessary: D. In temp should be made to weigh the patient at approximately the same time of day, if a sequence of weight is necessary 46. 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? A. Normal blood pressure B. Prehypertension C. Stage 1 hypertension D. Stage 2 hypertension: B. Prehypertension 47. During an examination of a child, the nurse considers that physical growth is the best index of a child's : A. general Health B. genetic makeup C. Nutritional status D. Activity and exercise patterns: A. general Health 48. 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: A. Refer the infant to a physician for further evaluations B. Consider these findings normal for a one-month old infant C. Expect the chest circumference to be greater than the head circumference D. Ask the parent to return in 2 weeks to reevaluate the head and chest circumferences: B. Consider these findings normal for a one-month old infant 49. The nurse is assessing and 80-year-old male patient. which assessment findings would be considered normal? A. Increase in body weight from his younger years B. Additional deposits at sat on the thighs and lower legs C. Presence of kyphosis and flexion in the knees and hips D. Change and overall body proportion, Including a longer trunk and shorter extremities: C. Presence of kyphosis and flexion in the knees and hips 50. The nurse should measure rectal temperatures in which of these patients? A. School age child B. Older adult C. Comatose adult D. Patient receiving oxygen my nasal cannula: C. Comatose adult 51. The nurse is preparing to measure the length, wait, just, and head circum- ference of a 6 month old infant. Which measurement technique is correct? A. Measuring the infants linked by using a tape measure B. Weighing the infant by placing him or her on an electronic standing scale C. Measuring the chest circumference at the nipple line with a tape measure D. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones: C. Measuring the chest circumference at the nipple line with a tape measure 52. The nurse knows that one advantage of the tympanic membrane ther- mometer is that: A. Rapid measurement is useful for uncooperative young children B. Using the TMT is the most accurate method for measuring body temperature in newborn infants C. Measuring temperature using the TMT is inexpensive D. Studies strongly supports the use of TMT in children under the age of 6 years: A. Rapid measurement is useful for uncooperative young children 53. When assessing an older adult, which vital signs changes occur with aging? A. Increase in pulse rate B. Widened pulse pressure C. Increase in body temperature D. Decrease in diastolic blood pressure: B. Widened pulse pressure 54. The nurses examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? A. Exercise B. Radiation C. Metabolism D. Food digestion: B. Radiation 55. When measuring a patient's body temperature, the nurse keeps in mind that the body temperature is influenced by : A. Constipation B. Patients emotional state C. Diurnal cycle D. Nocturnal Cycle: C. Diurnal cycle 56. When evaluating the temperature of older adults, the nurse should remem- ber which aspect about an older adult's body temperature? A. The body temperature of the older adult is lower than that is a younger adult B. In older adults, body temperature is approximately the same as that of a young child C. Body temperature depends on the type of thermometer used D. In the older adult the body temperature varies widely because of less effective heat control mechanisms: A. The body temperature of the older adult is lower than that is a younger adult 57. 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: A. Weight loss is probably the result of unhealthy eating habits B. Chronic diseases such as hypertension cause weight loss C. Unexplained weight loss often accompanies short term illnesses D. Weight loss is probably the result of a mental health dysfunction: C. Unex- plained weight loss often accompanies short term illnesses 58. 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: A. Assume that the patient is eager and interested in participating in the interview B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position C. Assume that the patient is having difficulty breathing and assist him to a supine position D. Recognize that a tripod position is often used when a patient is having respiratory difficulties: D. Recognize that a tripod position is often used when a patient is having respiratory difficulties 59. which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? A. Wait 30 minutes if the patient has ingested hot or iced liquids B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile C. Place the thermometer in front of the tongue and ask the patient to close his or her lips D. Check the Mercury in glass thermometer down to below 36.6 C before taking the temperature: B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile 60. The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding the use of the TMT? A. A tympanic temperature is more time consuming than a rectal temperature B. The tympanic method is more invasive and uncomfortable than the oral method C. The risk of cross-contamination is reduced, compared to the rectal route D. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery: C. The risk of cross-contamination is reduced, compared to the rectal route 61. To assess a rectal temperature accurately in an adult, the nurse would: A. Use a lubricated blunt tip thermometer B. Insert the thermometer 2 to 3 inches into the rectum C. Read the thermometer in place of up to 8 minutes if the patient is febrile D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette: A. Use a lubricated blunt tip thermometer 62. Which technique is correct when the nurse is assessing the radial pulse of a patient? The post is counted for: A. One minute if the rhythm is irregular B. 15 seconds and then multiplied by 4 if the rhythm is regular C. 2 full minutes to detect any variation in amplitude D. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities: A. One minute if the rhythm is irregular 63. When assessing a patient's pulse comment the nurse should also notice which of these characteristics? A. Force B. Pallor C. Capillary refill time D. Timing in the cardiac cycle: A. Force 64. 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 be to: A. Notify the physician immediately B. Consider this finding normal in children and young adults C. Check the child's blood pressure, and note any variation with respiration D. Document that this child has bradycardia and continue with the assess- ment: B. Consider this finding normal in children and young adults 65. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: A. Is usually recorded on a zero to 2-point scale B. Demonstrates elasticity of the vessel wall C. Is a reflection of the hearts stroke volume D. Reflects the blood volume in the arteries during diastole: C. Is a reflection of the hearts stroke volume 66. 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. Which statement is true concerning these results? A. The patient is experiencing tachycardia B. These are normal vital signs for a healthy, athletic adult C. The patients pulse rate is not normal, his physician should be notified D. On the basis of these readings, the patient should return to the clinic in 1 week: B. These are normal vital signs for a healthy, athletic adult 67. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern how should the nurse assess this child respirations? A. Respiration should be counted for one full minute, noticing the rate and rhythm B. Child pulse and respiration should be simultaneously checked for 30 sec- onds C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern D. Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute: A. Respiration should be counted for one full minute, noticing the rate and rhythm 68. A patient's blood pressure is 118/82 mmHg. He asks the nurse what do the numbers mean? The nurse's best reply is: A. The numbers are within the normal range and are nothing to worry about B. The bottom number is the diastolic pressure and reflects the stroke volume of the heart C. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts D. The concept of blood pressure is difficult to understand the primary thing to be concerned about is the top number, or the systolic blood pressure: C. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts 69. While measuring a patient's blood pressure, the nurse recalls that certain factors, such as , help determine blood pressure. A. Pulse rate B. Pulse pressure C. Vascular output D. Peripheral vascular resistance: D. Peripheral vascular resistance 70. 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: A. After menopause, blood pressure readings in women are usually lower than those taken in men B. The blood pressure of a black adult is usually higher than that of a white adult of the same age C. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight D. A teenager's blood pressure reading will be lower than that of an adult: B. The blood pressure of a black adult is usually higher than that of a white adult of the same age 71. 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: A. Yield have a falsely low blood pressure B. Yield a falsely high blood pressure C. Be the same, regardless of cuff size D. Vary as a result of the technique of the person performing the assessment- : B. Yield a falsely high blood pressure 72. A student is late for his appointment and has rushed across campus to the health clinic. the nurse should: A. Allow 5 minutes for him to relax and rest before checking his vital signs B. check the blood pressure in both arms comma expecting a difference in the readings because of his recent exercise C. Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later recording any differences D. check his blood pressure in the supine position which will provide a more accurate reading and will allow him to relax at the same time: A. Allow 5 minutes for him to relax and rest before checking his vital signs 73. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: A. More clearly hear the Korotkoff sounds B. Detect the presence of an auscultatory gap C. Avoid missing a falsely elevated blood pressure D. More readily identify phase IV of the Korotkoff sounds: B. Detect the presence of an auscultatory gap 74. The nurse is taking an initial blood pressure reading on 72-year-old patient with documented hypertension. How should the nurse proceed? A. Cuff should be placed on the patient's arm and then inflated 30 mm Hg above the patient's pulse rate B. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading C. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears D. After confirming the patients previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded: C. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears 75. 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? A. 10 B. 70 C. 80 D. 100: B. 70 76. 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? A. 200/92 B. 200/100 C. 100/200/92 D. 200/100/92: A. 200/92 77. 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? A. Blood pressure readings are taken in both the arms and the thighs B. Be patient is assisted to a lying position, and his blood pressure is taken C. His blood pressure is recorded in the lying, sitting, and standing positions D. His blood pressure is recorded in the lying and sitting positions, these numbers are than average to obtain a mean blood pressure: C. His blood pressure is recorded in the lying, sitting, and standing positions 78. What is the pulse pressure for a patient whose blood pressure is 158/96 mmHg and whose pulse rate is 72 bpm?: Answer 62 79. 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? A. These readings are normal response and attributable to changes in the patient's position B. The change in blood pressure readings is called orthostatic hypotension C. The blood pressure reading in the lying position is in within normal limits D. The changing blood pressure readings is considered within normal limits for this patient's age range: B. The change in blood pressure readings is called orthostatic hypotension 80. The nurse is helping another nurse take a blood pressure reading on a patients thigh. Which action is correct regarding the thigh pressure ? A. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure B. The best position to measure thigh pressure is in the supine position with the knee slightly bent C. If the blood pressure is high in an adolescent, then it should be compared with the thigh pressure D. The thigh pressure is lower than the pressure of the arm, which is attribut- able to the distance away from the heart and the size of the popliteal vessels- : C. If the blood pressure is high in an adolescent, then it should be compared with the thigh pressure 81. The nurse is preparing to measure the vital signs of a 6 month old infant. which action by the nurse is correct? A. Respirations are measured, then pulse and temperature B. Vital signs should be measured more frequently than in an adult C. Procedures are explained to the parent, and then the infant is encouraged to handle the equipment D. The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infant's vital signs: A. Respirations are measured, then pulse and temperature 82. A 4-month-old child is at the clinic for a well-baby checkup and immuniza- tions. which of these actions is most appropriate when a nurse is assessing the infant's vital signs? A. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise B. The nurse said auscultate and a pickle rate for one minute and then assess for any normal irregularities such as sinus arrhythmia C. the infant 's blood pressure should be assessed by using a stethoscope with a large diaphragm peace to hear the soft muffled Korotkoff sounds D. the infant's chest should be observed, and the respiratory rate counted for one minute; the respiratory pattern may vary slightly: B. The nurse said auscul- tate and a pickle rate for one minute and then assess for any normal irregularities such as sinus arrhythmia 83. The nurse is conducting a health fair for older adults. which statement is true regarding vital sign measurements in aging adults? A. The pulse is more difficult to palpate because of the stiffness of the blood vessels B. An increased respiratory rate and shallower inspiratory phase are expected findings C. A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressure readings D. Changes in the body's temperature regulatory mechanism leave the older person more likely to develop a fever: B. An increased respiratory rate and shallower inspiratory phase are expected findings 84. In a patient with acromegaly, the nurse will expect to discover which assessment findings? A. Heavy, flattened facial features B. Growth retardation and delayed onset of puberty C. Overgrowth of bone in the face, head, hands and feet D. Increased height and weight and delayed sexual development: C. Over- growth of bone in the face, head, hands and feet 85. The nurse is performing a general survey of a patient. Which finding is considered normal? A. When standing the patient's base is narrow B. The patient appears older than his stated age C. Arm span (fingertip to fingertip) is greater than the height D. Arm span (fingertip to fingertip) equals the patients height: D. Arm span (fingertip to fingertip) equals the patients height 86. The nurse is assessing pediatric children in a pediatric clinic. Which state- ment is true regarding the measurement of blood pressure in children? A. Blood pressure guidelines for children are based on age B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children C. Using a doppler device is recommended for accurate blood pressure mea- surements until adolescence D. The disappearance of phase V Korotkoff sounds can be used for the dias- tolic reading in children: D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children 87. 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? A. Diastolic blood pressure may not be heard B. Diastolic blood pressure may be falsely low C. Systolic blood pressure may be falsely low D. Systolic blood pressure may be falsely high: C. Systolic blood pressure may be falsely low 88. When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure is best described as which statemen? A. MAP is the pressure of the arterial pulse B. MAP reflects the stroke volume of the heart C. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle D. MAP is an average of the systolic and diastolic blood pressure and reflects tissue perfusion: C. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle 89. 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? A. Blood pressure and pulse should be recorded in the supine, sitting and standing positions B. The patient should be directed to walk around the room and his blood pressure assessed after this activity C. Blood pressure and pulse are assessed at the beginning and at the end of the examination D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm: A. Blood pressure and pulse should be recorded in the supine, sitting and standing positions 90. Which of these specific measurements is the best index of a child's general health? A. Vital signs B. Height and weight C. Head circumference D. Chest circumference: B. Height and weight 91. 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 condi- tion does this child have? A. Hypopituitary dwarfism B. Achondroplastic dwarfism C. Marfan syndrome D. Acromegaly: A. Hypopituitary dwarfism 92. The nurse is counting an infant's respirations. Which technique is correct? A. Watching the chest rise and fall B. Watching the abdomen for movement C. Placing a hand across the infants chest D. Using a stethoscope to listen to the breath sounds: B. Watching the abdomen for movement 93. When checking for the proper blood pressure cuff size, which guideline is correct? A. The standard cuff size is appropriate for all sizes B. The length of the rubber bladder should equal 80% of the arm circumfer- ence C. The width of the bladder should equal 80% of the arm circumference D. The width of the rubber bladder should equal 40% of the arm circumference- : D. The width of the rubber bladder should equal 40% of the arm circumference 94. 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? A. Marfan syndrome B. Gigantism C. Cushing syndrome D. Acromegaly: C. Cushing syndrome 95. While measuring a patient's blood pressure, the nurse uses proper tech- nique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply A. The person supports his or her own arm during the blood pressure reading B. The blood pressure cuff is too narrow for the extremity C. The arm is held above the level of the heart D. The cuff is loosely wrapped around the arm E. The person is sitting with his or her legs crossed F. The nurse does not inflate the cuff high enough: Answer A, B, D, E 96. The nurse is testing a patient's visual accommodation, which refers to which action ? A. The eyes converge to focus on the light B. Light is reflected at the same spot in both eyes C. The eye focuses the image in the center of the people D. Constriction of both pupils occurs in response to bright light: D. Constriction of both pupils occurs in response to bright light 97. 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: A. Just above the diaphragm B. Just lateral to the knee cap C. At the level of the C 7 vertebra D. At the level of the T 11 vertebra: C. At the level of the C 7 vertebra 98. 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 be: A. Perhaps that could be a result of your dietary intake during pregnancy B. Your baby may have craniosynostosis, a disease of the sutures of the brain C. The soft spot may be an indication of cretinism or congenital hypothy- roidism D. That soft spot is normal, and actually allows for growth of the brain during the first your of your baby's life.*: 99. 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? A. III B. V C. VII D. I: C. VII 100. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: A. Bell Palsy C. Parotid, submandibular C. Frostbite with resultant paresthesia to the cheeks D. Scleroderma: C. Parotid, submandibular 101. 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. A. Occipital, submental B. Parotid, jugulodigastric C. Parotid, submandibular D. Submandibular, occipital: C. Parotid, submandibular 102. 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 . A. XI, palpating the anterior and posterior triangles B. XI, asking the patient to shrug her shoulders against resistance C. XII, percussing the SCM and submandibular neck muscles D. XII, assessing for a positive Romberg sign: B. XI, asking the patient to shrug her shoulders against resistance 103. When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the A. Sternomastoid and trapezius B. Spinal accessory and omohyoid C. Trapezius and sternomandibular D. Sternomandibular and spinal accessory: A. Sternomastoid and trapezius 104. A patient's laboratory data reveal an elevated t4 level. The nurse would proceed with an examination of the gland. A. Thyroid B. Parotid C. Adrenal D. Parathyroid: A. Thyroid 105. A patient says that she has recently noticed a lump in the front of her neck below her Adam's apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump: A. Is tender B. Is mobile and not hard C. Disappears when the patient smiles D. Is hard and fixed to the surrounding structures: B. Is mobile and not hard 106. 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 A. Infraclavicular area B. Supraclavicular area C. Area distal to the enlarged node D. Area proximal to the enlarged node: D. Area proximal to the enlarged node 107. The nurse is aware that the four area in the body where lymph nodes are accessible are the: A. Head, breasts, groin and abdomen B. Arms, breasts, inguinal area, and legs C. Head and neck, arms, breasts and axillae D. Head and neck, arms, inguinal area, and axillae: D. Head and neck, arms, inguinal area, and axillae 108. 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? A. At birth the head is one fifth the total length B. Head circumference should be greater than chest circumference at birth C. He had reaches 90% of his final size when the child is 3 years old D. When the anterior fontanelle closes at 2 months, the head will be more proportionate to the body: B. Head circumference should be greater than chest circumference at birth 109. 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? A. Diet low in protein and high in carbohydrates make cause enhanced facial bones B. Bones can become more noticeable if the person does not use a dermato- logically approved moisturizer C. More noticeable facial bones are probably due to a combination of factors related to aging, such as it decreased elasticity, subcutaneous fat, and mois- ture in the skin D. Facial skin becomes more elastic with age. this increased elasticity causes the skin to be more taught, drawing attention to the facial bones: C. More noticeable facial bones are probably due to a combination of factors related to aging, such as it decreased elasticity, subcutaneous fat, and moisture in the skin 110. 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: A. Hypertension B. Cluster headaches C. Tension headaches D. Migraine headaches: B. Cluster headaches 111. 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 be suffering from: A. Hypertension B. Cluster headaches C. Tension headaches D. Migraine headaches: D. Migraine headaches 112. 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? A. Head injury B. Cluster headache C. Migraine headache D. Meningeal inflammation: D. Meningeal inflammation 113. During a well-baby checkup, the nurse notices that a one-week old in- fant'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? A. Craniotabes B. Microcephaly C. Hydrocephalus D. Caput succedaneum: C. Hydrocephalus 114. The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: A. Hyoid bone B. Vagus nerve C. Tragus D. Mandible: C. Tragus 115. 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 be 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 be an inflammation of his: A. Thyroid gland B. Parotid gland C. Occipital lymph node D. Submental lymph node: B. Parotid gland 116. 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: A. Thyroid gland B. Parotid gland C. Cervical lymph nodes D. Mouth and skin for lesions: B. Parotid gland 117. 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? A. Tachycardia B. Constipation C. Rapid dyspnea D. Atrophied nodular thyroid gland: A. Tachycardia 118. A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. he would probably be more comfortable with the nurse examining his thyroid gland from: A. Behind with the nurse's hands placed firmly around his neck B. The side with the nurse's eyes averted toward the ceiling and thumbs on his neck C. The front with the nurse's thumbs placed on either side of his trachea in his head tilted forward D. The front with the nurse's thumbs placed on either side of his trachea with his head tilted backward: C. The front with the nurse's thumbs placed on either side of his trachea in his head tilted forward 119. A patient's thyroid gland is enlarged, and the nurse is preparing to aus- cultate 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, diaphragm B. Loud wooshing, blowing, bell C. Soft wooshing, pulsatile, bell D. High-pitched tinkling, diaphragm: C. Soft wooshing, pulsatile, bell 120. 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 A. Hydrocephalus B. Craniosynostosis C. Cephalhematoma D. Caput succedaneum: C. Cephalhematoma 121. 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: A. Abnormal and is called the atonic neck reflex B. Normal and should disappear by the first year of life C. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age D. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.: C. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age 122. 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: A. Exophthalmus B. Bowed long bones C. Coarse facial features D. Acorn-shaped cranium: C. Coarse facial features 123. When examining children affected with Down syndrome (trisomy 21) the nurse looks for the possible presence of A. Ear dysplasia B. Long, thin neck C. Protruding thin tongue D. Narrow and raised nasal bridge: A. Ear dysplasia 124. 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: A. Cushing syndrome B. Parkinson disease C. Bell palsy D. Experienced a CVA or stroke: C. Bell palsy 125. 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: A. Cachexia B. Parkinson Syndrome C. Myxedema D. Scleroderma: C. Myxedema 126. During an examination of a female patient, the nurse notes lym- phadenopathy and suspects and acute infection. Acutely infected lymph nodes would be: A. Clumped B. Unilateral C. Firm by freely moveable D. Firm and nontender: C. Firm by freely moveable 127. 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: A. Pulled to the affected side B. Pushed to the unaffected side C. Pulled downward D. Pulled downward in a rhythmic pattern: B. Pushed to the unaffected side 128. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? A. Rickets B. Dehydration C. Mental retardation D. Increased intracranial pressure: B. Dehydration 129. 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: A. Allergies B. Sinus infection C. Nasal congestion D. Upper respiratory infection: A. Allergies 130. 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: A. Has chronic allergies B. May have an infection C. Is exhibiting a normal finding for a well child of this age D. Should be referred for additional evaluation: C. Is exhibiting a normal finding for a well child of this age 131. 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: A. Shotty B. Nonpalpable C. Large, firm, and fixed to the tissue D. Rubbery, discrete and mobile: B. Nonpalpable 132. 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 enlarge- ment had been previously noticed. The nurse suspects that the patient: A. Has an iodine deficiency B. Is exhibiting early signs of goiter C. Is exhibiting a normal enlargement of the thyroid gland during pregnancy D. Needs further testing for possible thyroid cancer: C. Is exhibiting a normal enlargement of the thyroid gland during pregnancy 133. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck to described by which statement? A. Using gentle pressure, palpate with both hands to compare the two sides B. Using strong pressure, palpate with both hands to compare the two sides C. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle D. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern: A. Using gentle pressure, palpate with both hands to compare the two sides 134. 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? A. Head control is usually achieved by 4 months of age B. You shouldn't be trying to pull your baby up like that until she is older C. Head control should be achieved by this time D. This inability indicates possible nerve damage to the neck muscles: A. Head control is usually achieved by 4 months of age 135. During an examination of a 3-year-old child, the nurse notices a bruit Over the left temporal area. the nurse should: A. Continue the examination because a bruit is a normal finding for this age B. Check for the bruit again in 1 hour C. Notify the parents that a bruit has been detected in their child D. Stop the examination and notify the physician: A. Continue the examination because a bruit is a normal finding for this age 136. 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? A. Crepitation B. Mastoiditis C. Temporal arteritis D. Bell palsy: C. Temporal arteritis 137. 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 A. Head circumference equal to chest circumference B. Head circumference greater than chest circumference C. Head circumference less than chest circumference D. Fontanels firm and slightly concave E. Absent tonic neck reflex F. Non-palpable cervical lymph nodes: Answer B,D,F 138. When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: A. Is expected B. May indicate a problem with extraocular muscles C. May result in problems with tearing D. Indicates increased intraocular pressure: A. Is expected 139. During the ocular examinations, the nurse keeps in mind that movement of the extra ocular muscles is: A. Decreased in the older adult B. Impaired in a patient with cataracts C. Stimulated by cranial nerves I and II D. Stimulated by CNs II IV and VI: D. Stimulated by CNs II IV and VI 140. The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? A. The outer layer of the eye is very sensitive to touch B. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally C. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated D. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye: A. The outer layer of the eye is very sensitive to touch 141. When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: A. Causes pupillary constriction B. Adjust the eye for near vision C. Elevates the eyelid and dilates the pupil D. Causes constriction of the ciliary body: C. Elevates the eyelid and dilates the pupil 142. The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? A. Thickness or bulging of the lens B. Posterior chamber as it accommodates increased fluid C. Contraction of the ciliary body in response to the aqueous within the eye D. Amount of aqueous produced in resistance to it out flow at the angle of the anterior chamber: D. Amount of aqueous produced in resistance to it out flow at the angle of the anterior chamber 143. The nurse is conducting a visual examination. which of the statements regarding visual pathways and visual field is true? A. The right side of the brain interprets vision for the right eye B. The image formed on the retina is upside down in reversed from its actual appearance in the outside world C. Light Rays are refracted through the transparent media of the eye before striking the people D. Light impulses are conducted through the optic nerve to the temporal lobes of the brain: B. The image formed on the retina is upside down in reversed from its actual appearance in the outside world 144. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: A. Vision is not totally developed until 2 years of age B. Infants develop the ability to focus on an object at approximately 8 months of age C. By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object D. Most infants have uncoordinated eye movements for the first year of life.: C. By approximately 3 months of age, infants develop more coordinated eye move- ments and can fixate on an object 145. The nurse is reviewing age related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? A. Degeneration of the cornea B. Loss of lens elasticity C. Decreased adaptation to darkness D. Decreased distance in vision abilities: B. Loss of lens elasticity 146. Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? A. Increased night vision B. Dark retinal background C. Increased photosensitivity D. Narrowed palpebral fissures: B. Dark retinal background 147. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should A. Examine the r