NURS 112: NCLEX questions - Taylor Ch 25 Questions
With Complete Solutions
A nurse has explained her intention to conduct Weber's test and
Rinne's test. Which of the following pieces of equipment will
the nurse require?
a) Ophthalmoscope
b) Otoscope
c) Snellen chart
d) Tuning fork Correct Answer d) Tuning fork
Weber's test and Rinne's test are performed in order to assess
sound conduction; both require a tuning fork.
A nurse is conducting an assessment of a patient's cranial
nerves. The nurse asks the patient to raise the eyebrows, smile,
and show the teeth to assess which cranial nerve?
a) Olfactory
b) Optic
c) Facial
d) Vagus Correct Answer c) Facial
Motor function of the facial nerve (cranial nerve VII) is assessed
by asking the patient to raise the eyebrow, smile, and show the
teeth.
A nurse who works on a day-surgery unit conducts a thorough,
head to toe assessment of each patient prior to the patient's
,scheduled surgery. The nurse would document an unexpected
finding if unable to palpate a patient's:
a) liver.
b) thyroid gland.
c) lymph nodes.
d) peripheral pulses. Correct Answer d) peripheral pulses.
Nonpalpable peripheral pulses are an unexpected finding, which
warrants further assessment and follow-up. The liver, lymph
nodes, and thyroid are not normally palpable in healthy
individuals.
A patient's visual acuity is assessed as 20/40 in both eyes using
the Snellen chart. The nurse interprets this finding as which of
the following?
a) The patient can see twice as well as normal
b) The patient has double vision
c) The patient has less than normal vision
d) The patient has normal vision Correct Answer Normal
vision is 20/20. A finding of 20/40 would mean that a patient
has less than normal vision.
After inspecting a patient's abdomen, which technique would the
nurse do next?
a) Percussion
b) Palpation
c) Auscultation
, d) Whichever the patient agrees to Correct Answer c)
Auscultation
When assessing the abdomen, the sequence is inspection,
auscultation, percussion, and palpation. Auscultation follows
inspection because percussion and palpation stimulate bowel
sounds.
An older adult asks the nurse about the appearance of flat brown
age spots on the hands. After examining the patient's hands, the
nurse recognizes these skin characteristics as a common skin
variation in the older adult and documents the variations as
which of the following?
a) Senile keratosis
b) Senile lentigines
c) Cherry angiomas
d) Lanugo Correct Answer b) Senile lentigines
Senile lentigines are flat brown age spots, senile keratosis are
raised dark areas, and cherry angiomas are small round red spots
and all are common skin variations in the older adult. Lanugo is
a fine downy hair that appears on the newborn for the first 2
weeks of life.
As a component of a head to toe assessment, Nurse G. is
preparing to assess convergence of the patient's eyes. How
should Nurse G. conduct this assessment?
a) Ask the patient to read a Snellen chart from a distance of 20
feet.
With Complete Solutions
A nurse has explained her intention to conduct Weber's test and
Rinne's test. Which of the following pieces of equipment will
the nurse require?
a) Ophthalmoscope
b) Otoscope
c) Snellen chart
d) Tuning fork Correct Answer d) Tuning fork
Weber's test and Rinne's test are performed in order to assess
sound conduction; both require a tuning fork.
A nurse is conducting an assessment of a patient's cranial
nerves. The nurse asks the patient to raise the eyebrows, smile,
and show the teeth to assess which cranial nerve?
a) Olfactory
b) Optic
c) Facial
d) Vagus Correct Answer c) Facial
Motor function of the facial nerve (cranial nerve VII) is assessed
by asking the patient to raise the eyebrow, smile, and show the
teeth.
A nurse who works on a day-surgery unit conducts a thorough,
head to toe assessment of each patient prior to the patient's
,scheduled surgery. The nurse would document an unexpected
finding if unable to palpate a patient's:
a) liver.
b) thyroid gland.
c) lymph nodes.
d) peripheral pulses. Correct Answer d) peripheral pulses.
Nonpalpable peripheral pulses are an unexpected finding, which
warrants further assessment and follow-up. The liver, lymph
nodes, and thyroid are not normally palpable in healthy
individuals.
A patient's visual acuity is assessed as 20/40 in both eyes using
the Snellen chart. The nurse interprets this finding as which of
the following?
a) The patient can see twice as well as normal
b) The patient has double vision
c) The patient has less than normal vision
d) The patient has normal vision Correct Answer Normal
vision is 20/20. A finding of 20/40 would mean that a patient
has less than normal vision.
After inspecting a patient's abdomen, which technique would the
nurse do next?
a) Percussion
b) Palpation
c) Auscultation
, d) Whichever the patient agrees to Correct Answer c)
Auscultation
When assessing the abdomen, the sequence is inspection,
auscultation, percussion, and palpation. Auscultation follows
inspection because percussion and palpation stimulate bowel
sounds.
An older adult asks the nurse about the appearance of flat brown
age spots on the hands. After examining the patient's hands, the
nurse recognizes these skin characteristics as a common skin
variation in the older adult and documents the variations as
which of the following?
a) Senile keratosis
b) Senile lentigines
c) Cherry angiomas
d) Lanugo Correct Answer b) Senile lentigines
Senile lentigines are flat brown age spots, senile keratosis are
raised dark areas, and cherry angiomas are small round red spots
and all are common skin variations in the older adult. Lanugo is
a fine downy hair that appears on the newborn for the first 2
weeks of life.
As a component of a head to toe assessment, Nurse G. is
preparing to assess convergence of the patient's eyes. How
should Nurse G. conduct this assessment?
a) Ask the patient to read a Snellen chart from a distance of 20
feet.
