Exam 2: NSG3160 / NSG 3160 (Latest 2026 / 2027) Health Assessment | 100% Correct Questions & Answers - Galen

Exam 2: NSG3160 / NSG 3160 (Latest 2026 / 2027) Health Assessment | 100% Correct Questions & Answers - Galen During a mental status assessment, which question by the nurse would best assess a person's judgment? A "Do you feel that you are being watched, followed, or controlled?" B "What would you do if you found a stamped, addressed envelope lying on the sidewalk?" C "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D "Tell me what you plan to do once you are discharged from the hospital." D "Tell me what you plan to do once you are discharged from the hospital." The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore to assess the mental status during the interview? A "I have no health problems." B "I never did too good in school." C "I am not currently taking any medications." D "I sleep like a baby." B "I never did too good in school." During an examination, the nurse can assess mental status by which activity? A Observing the patient as he or she performs an intelligence quotient (IQ) test B Examining the patient's response to a specific set of questions C Observing the patient and inferring health or dysfunction D Examining the patient's electroencephalogram C Observing the patient and inferring health or dysfunction When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? A "After the seizure, do you spend a lot of time sleeping?" B "Do you have any warning sign before your seizure starts?" C "Do you experience any color change or incontinence during the seizure?" D "Does your muscle tone seem tense or limp?" B "Do you have any warning sign before your seizure starts? During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? A These findings are normal, resulting from aging. B These findings could be r/t hyperthyroidism. C These findings are the result of Parkinson disease. D This patient should be evaluated for a cerebellar lesion. A These findings are normal, resulting from aging. A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. What does the nurse suspect? A Cerebral injury B Peripheral neuropathy C Cerebrovascular accident D Acute alcohol intoxication D Acute alcohol intoxication When assessing the intensity of a patient's pain, which question by the nurse is appropriate? A "How does pain limit your activities?" B "What does your pain feel like?" C "How much pain do you have now?" D "What makes your pain better or worse?" C "How much pain do you have now?" The nurse is teaching a class on pain at a local retirement community. Which statement about the pain experienced by older adults should the nurse include in the instructions? A "Pain is a normal process of aging and is to be expected." B "Pain indicates a pathologic condition or an injury and is not a normal process of aging." C "Older adults must learn to tolerate pain." D "Older individuals perceive pain to a lesser degree than do younger individuals." B "Pain indicates a pathologic condition or an injury and is not a normal process of aging." The nurse is conducting an interview with an adult male patient. Which statement made by the patient indicates an alcohol use disorder? A "I usually stay out longer and drink more than I intended but I still make it into work on time." B "I've been late to work a few times so now I limit myself to 2 drinks/day and stick to it." C "I have a strong urge to drink and I've tried to stop drinking several times but it doesn't last long." D "I crave alcohol but have successfully cut down on my alcohol consumption." C "I have a strong urge to drink and I've tried to stop drinking several times but it doesn't last long." The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? A State, "You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm willing to help you." B Give the patient information about a local rehabilitation clinic. C Record the results of the assessment, and notify the physician on call. D State, "It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter." A State, "You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm willing to help you." During a mental status examination, the nurse wants to assess a patient's affect. Which question the nurse should ask? A "Have these medications had any effect on your pain?" B "Would you please repeat the following words?" C "Has this pain affected your ability to get dressed by yourself?" D "How do you feel today?" D "How do you feel today?" A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? A Plan to integrate the mental status examination into the history and physical examination. B Reassure his wife that memory loss after a physical shock is normal and will soon subside. C Perform a complete mental status examination. D Refer him to a psychometrician. C Perform a complete mental status examination. The nurse is providing instructions to a newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination? A The MMSE is a useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time. B The MMSE is a good tool to evaluate mood and thought processes. C This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. D Scores below 30 indicate cognitive impairment. C This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? A "Does the tremor change when you drink alcohol?" B "We'll do some tests to see what is causing the tremor." C "You really shouldn't drink so much alcohol; it may be causing your tremor." D "Does your family know you are drinking every day?" A "Does the tremor change when you drink alcohol?" The nurse is assessing a patient's pain. What should the nurse know is the most reliable indicator of pain? A Patient's vital signs B Subjective report C Results of a computerized axial tomographic scan D Physical examination B Subjective report A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? A Hyperventilation B Increased blood pressure and pulse C Depression D Confusion B Increased blood pressure and pulse During an assessment, the nurse asks a female patient, "How many alcoholic drinks do you have a week?" Which answer by the patient would indicate at-risk drinking? A "I usually have three or four drinks a week." B "I'll have a glass or two of wine every now and then." C "I have eight to ten drinks a week, but I never get drunk." D "I may have one or two drinks a week." C "I have eight to ten drinks a week, but I never get drunk." When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk for alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? (Select all that apply.) Increased muscle mass Increased cardiac output Decreased kidney functioning Decreased blood pressure Decreased liver metabolism Decreased kidney functioning & Decreased liver metabolism The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the assessment? A Will have difficulty on tests of remote memory because this ability typically decreases with age. B Will have no decrease in any of his abilities, including response time. C Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge. D May take a little longer to respond, but his general knowledge and abilities should not have declined. D May take a little longer to respond, but his general knowledge and abilities should not have declined. During change of shift report, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? A Man believes that his dead wife is talking to him. B Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket. C Woman hears the doorbell ring and goes to answer it, but no one is there. D Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. A Man believes that his dead wife is talking to him. A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting for a while, she gets "really dizzy" and feels like she is going to fall over. What is the best response by the nurse? A "You need to get up slowly when you've been lying down or sitting." B "Have you been extremely tired lately?" C "You probably just need to drink more liquids." D "I'll refer you for a complete neurologic examination." A "You need to get up slowly when you've been lying down or sitting." The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. How should the nurse interpret these findings? A Achilles reflex, which is an expected response B Clonus, which is a hyperactive response C Negative Babinski sign, which is normal for adults D Positive Babinski sign, which is abnormal for adults D Positive Babinski sign, which is abnormal for adults A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? A Reflexes will be normal. B Some reflexes will be present, depending on the area of injury. C Reflexes cannot be elicited. D All reflexes will be diminished but present. A Reflexes will be normal. A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain? A Numeric rating scale B Descriptor scale C Brief pain inventory D Faces Pain Scale—Revised (FPS-R) D Faces Pain Scale—Revised (FPS-R) A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1-to-10 scale. What is the likely reason for this? A The patient does not want to trouble the nursing staff with her complaints. B The patient has experienced chronic pain for years and has adapted to it. C The patient is not in pain but rates it high to receive pain medication. D The patient is addicted to her pain medications and cannot obtain pain relief. B The patient has experienced chronic pain for years and has adapted to it. The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, "Yes, I've used marijuana at parties with my friends." What is the next question the nurse should ask? A "When was the last time you used marijuana?" B "Do your parents know about this?" C "Who are these friends?" D "Is this a regular habit?" A "When was the last time you used marijuana?" The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? A Peripheral neuropathy B Lesion of sensory cortex C Hyperalgesia D Hyperesthesia A Peripheral neuropathy When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding? A Ataxia B Positive Romberg sign C Lack of coordination D Negative Homan sign B Positive Romberg sign The nurse is evaluating a patient's pain. Which is an example of acute pain? A Lower back pain B Arthritic pain C Kidney stones D Fibromyalgia C Kidney stones When assessing aging adults, what is one of the first things the nurse should assess before making judgments about the aging person's mental status? A Sensory-perceptive abilities B General intelligence C Presence of phobias D Presence of irrational thinking patterns A Sensory-perceptive abilities A 45-year-old woman is at the clinic for a mental status assessment. Which describes the expecting findings on the Four Unrelated Words Test? A Recalls four unrelated words after a 60-minute delay B Recalls four unrelated words after a 30-minute delay C Invents four unrelated words within 5 minutes D Invents four unrelated words within 30 seconds B Recalls four unrelated words after a 30-minute delay During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? A The nurse would not test the sensory system as part of the examination because the results would not be valid. B The nurse would proceed with an explanation of each test, making certain that the wife understands. C Before testing, the nurse would assess the patient's mental status and ability to follow directions. D The nurse would perform the tests, knowing that mental status does not affect sensory ability. C Before testing, the nurse would assess the patient's mental status and ability to follow directions. The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? A The patient has hyperesthesia as a result of the aging process. B The nurse was probably not poking hard enough with the pin in the other areas. C This response is most likely the result of the summation effect. D The patient most likely has analgesia in some areas of arm and hyperalgesia in others. C This response is most likely the result of the summation effect. A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? A Telling the patient that the pain medication must wait until after the x-ray images are completed B Completing the physical examination first and then giving the pain medication C Evaluating the full range of motion of the knee and then medicating for pain D Administering pain medication and then proceeding with the assessment D Administering pain medication and then proceeding with the assessment During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? (Select all that apply.) Restlessness Sleeping Bracing Rubbing Moaning Diaphoresis Sleeping, bracing, rubbing A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first? A Memory and affect B Level of consciousness C Cognitive abilities D Affect and mood B Level of consciousness A patient has been in the intensive care unit for 10 days. He has just been moved to the medical surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient's tests of cognitive function? A Will state, "I am so relieved to be out of intensive care." B May show evidence of some clouding of his level of consciousness. C May display some disruption in thought content. D Will be oriented to place and person, but the patient may not be certain of the date. D Will be oriented to place and person, but the patient may not be certain of the date. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A Level of consciousness, motor function, pupillary response, and vital signs B Mental status, deep tendon reflexes, sensory function, and pupillary response C Deep tendon reflexes, vital signs, and coordinated movements D CNs, motor function, and sensory function A Level of consciousness, motor function, pupillary response, and vital signs During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. How should the nurse interpret these findings? A Normal changes attributable to aging B CNS dysfunction C Demyelination of nerves attributable to a lesion D Lesion in the cerebral cortex A Normal changes attributable to aging During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? (Select all that apply.) Have the patient rate pain on a 1-to-10 scale. Ask the patient, "Do you have pain?" Note whether the patient is calling out, groaning, or crying. Observe the patient's body language for pacing and agitation. Assess the patient's breathing independent of vocalization. Note whether the patient is calling out, groaning, or crying. Observe the patient's body language for pacing and agitation. Assess the patient's breathing independent of vocalization. The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance? A A person experiences a syndrome of physiologic symptoms if the substance is not used. B A person requires an increased amount of the substance to produce the same effect. C A physiologic dependence on a substance. D A person requires daily use of the substance to function and is unable to stop using it. B A person requires an increased amount of the substance to produce the same effect. A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? A "Are you feeling so hopeless that you feel like hurting yourself now?" B "People often feel hopeless, but the feelings resolve within a few weeks." C "How do other people treat you?" D "Do you have a weapon?" A "Are you feeling so hopeless that you feel like hurting yourself now?" The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A Mental disorders occur in response to everyday life stressors. B Mental status assessment diagnoses specific psychiatric disorders. C Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds). D Mental status functioning is inferred through the assessment of an individual's behaviors. D Mental status functioning is inferred through the assessment of an individual's behaviors. A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. Which is an appropriate conclusion for the nurse draw? A She is only trying to shock people and that her dress should be ignored. B She has a manic syndrome because of her abnormal dress and grooming. C She probably does not have any problems. D More information should be gathered to decide whether her dress is appropriate. D More information should be gathered to decide whether her dress is appropriate. When the nurse is testing the triceps reflex, what is the expected response? A Pronation of the hand B Extension of the forearm C Flexion of the forearm D Flexion of the hand B Extension of the forearm A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? A Complete neurologic examination B Glasgow Coma Scale C Screening neurologic examination D Neurologic recheck examination A Complete neurologic examination While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. What does this finding indicate? A Great sense of humor B Decreased level of consciousness C Uncooperative behavior D Inability to understand questions B Decreased level of consciousness A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. How should the nurse proceed? A Defer the rest of the mental status examination. B Proceed with the examination and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression. C Conduct an in-depth speech evaluation and defer the mental status examination to another time. D Skip the language portion of the examination and proceed onto assessing mood and affect. A Defer the rest of the mental status examination. During an assessment of the cranial nerves (CNs), the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. These findings indicate dysfunction of which cranial nerve(s) A Motor component of CN IV B Motor and sensory components of CN XI C Motor component of CN X and sensory component of CN VII D Motor component of CN VII D Motor component of CN VII During a session on substance abuse, the nurse is reviewing statistics with the class. For people aged 12 years and older, which illicit substance was most commonly used? A Heroin B Hallucinogens C Crack cocaine D Marijuana D Marijuana The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? (Select all that apply.) Person demonstrates apraxia. Person exhibits memory impairment or deficits. Occurs as a result of a medical condition, such as systemic infection. Person experiences agnosia. Develops over a short period. Person exhibits memory impairment or deficits. Occurs as a result of a medical condition, such as systemic infection. Develops over a short period. Which of these individuals would the nurse consider at highest risk for a suicide attempt? A Woman who, during a past episode of major depression, attempted suicide B Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun C Adolescent who just broke up with her boyfriend and states that she would like to kill herself D Man who jokes about death B Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? A More noticeable facial bones are probably due to a combination of factors r/t aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. B Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. C Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones. D Diets low in protein and high in carbohydrates may cause enhanced facial bones. A More noticeable facial bones are probably due to a combination of factors r/t aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination? A XII; assess for a positive Romberg sign. B XII; percuss the sternomastoid and submandibular neck muscles. C XI; have patient shrug their shoulders against resistance. D XI; palpate the anterior and posterior triangles. C XI; have patient shrug their shoulders against resistance. The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? A Convergence of the axes of the eyes B Consensual light reflex C Dilation of the pupils D Disconjugate movement of the eyes A Convergence of the axes of the eyes The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? A Presence of the macula located on the nasal side of the retina. B Presence of pigmented crescents in the macular area. C Optic disc margins that are blurred around the edges. D Optic disc that is a yellow-orange color. D Optic disc that is a yellow-orange color. The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? A The presence of cerumen is indicative of poor hygiene. B Cerumen is necessary for transmitting sound through the auditory canal. C The purpose of cerumen is to protect and lubricate the ear. D Wet, honey-colored cerumen is a sign of infection. C The purpose of cerumen is to protect and lubricate the ear. The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? (Select all that apply.) Sounds may be garbled and difficult to localize. The aging person may find it harder to hear consonants than vowels. Hearing loss r/t aging begins in the mid-40s. Hearing loss reflects nerve degeneration of the middle ear. Progression of hearing loss is slow. The aging person has low-frequency tone loss. Sounds may be garbled and difficult to localize. The aging person may find it harder to hear consonants than vowels. Progression of hearing loss is slow. What is the tissue that connects the tongue to the floor of the mouth called? A Papillae B Palate C Uvula D Frenulum D Frenulum During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.) Chronic allergies Herpes simplex virus I Cigarette smoking Chronic alcohol use Frequent episodes of strep throat Aging Chronic allergies Cigarette smoking Aging When assessing the tongue of an adult, what finding would be considered abnormal? A Smooth glossy dorsal surface B Raised papillae on the dorsal surface C Visible venous patterns on the ventral surface D Thin white coating over the tongue A Smooth glossy dorsal surface 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. What does the nurse suspect is the cause of these signs and symptoms? A Lymphadenopathy B Chronic allergies C Nasal congestion D Upper respiratory infection B Chronic allergies When examining a patient's CN function, what muscles should the nurse assess to assess the function of CN XI? A Sternomastoid and trapezius B Spinal accessory and omohyoid C Sternomandibular and spinal accessory D Trapezius and sternomandibular A Sternomastoid and trapezius When assessing the pupillary light reflex, the nurse should use which technique? A Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. B Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose. C Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. D Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. D Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. How should the nurse proceed? A Understand that floaters are usually insignificant and are caused by condensed vitreous fibers. B Examine the retina to determine the number of floaters. C Consider these to be abnormal findings, and refer him to an ophthalmologist. D Presume the patient has glaucoma and refer him for further testing. A Understand that floaters are usually insignificant and are caused by condensed vitreous fibers. The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? A Using the smallest speculum to decrease the amount of discomfort. B Once the speculum is in the ear, releasing the traction. C Tilt the person's head forward during the examination. D Pulling the pinna up and back before inserting the speculum. D Pulling the pinna up and back before inserting the speculum. The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? A High-tone frequency loss B Thin, translucent membrane C Shiny, pink tympanic membrane D Increased elasticity of the pinna A High-tone frequency loss The nurse is performing an oral assessment on a 40-year-old black patient and notices the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true about this lesion? A It is indicative of cancer and should be immediately tested. B It is leukoedema which is common in dark-pigmented people. C It is the result of hyperpigmentation and is a normal finding. D It is torus palatinus and would normally be found only in smokers. B It is leukoedema which is common in dark-pigmented people. During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? A Yellow fatty deposits over the cornea B Yellow color of the sclera that extends up to the iris C Pallor near the outer canthus of the lower lid D Presence of small brown macules on the sclera D Presence of small brown macules on the sclera During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? A Absence of drainage from the puncta when pressing against the inner orbital rim B Presence of tears along the inner canthus C Blocked nasolacrimal duct in a newborn infant D Slight swelling over the upper lid and along the bony orbit if the individual has a cold A Absence of drainage from the puncta when pressing against the inner orbital rim The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? A Pain during palpation B Pain sensation behind eyes C No sensation D Firm pressure D Firm pressure During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? A Assess for other signs of insufficient oxygen supply. B Ask if he has been exposed to an excessive amount of carbon monoxide. C Check the patient's Hb for anemia. D Proceed with the assessment, this appearance is a normal finding. D Proceed with the assessment, this appearance is a normal finding. A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. How should the nurse proceed that would allow the patient to feel more comfortable with the nurse examining his thyroid gland? A The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward B Behind with the nurse's hands placed firmly around his neck C The side with the nurse's eyes averted toward the ceiling and thumbs on his neck D The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward D The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward The nurse is reviewing the age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? A Degeneration of the cornea B Decreased adaptation to darkness C Decreased distance vision abilities D Loss of lens elasticity D Loss of lens elasticity The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? A Presence of arcus senilis observed around the cornea B Decrease in tear production C Unequal pupillary constriction in response to light D Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles C Unequal pupillary constriction in response to light In performing a voice test to assess hearing, which of these actions would the nurse perform? A Stand approximately 4 feet away to ensure that the patient can really hear at this distance. B Whisper a set of random numbers and letters, and then ask the patient to repeat them. C Shield the lips so that the sound is muffled. D Ask the patient to place his or her finger in their ear to occlude outside noise. B Whisper a set of random numbers and letters, and then ask the patient to repeat them. The nurse needs to palpate the temporomandibular joint for crepitation. Where is this joint located? A Just below the vagus nerve and posterior to the mandible B Just below the temporal artery and anterior to the tragus C Just below the temporal artery and anterior to the mandible D Just below the hyoid bone and posterior to the tragus B Just below the temporal artery and anterior to the tragus The nurse is performing the diagnostic positions test. Which result is a normal finding? A Convergence of the eyes B Parallel movement of both eyes C Nystagmus in extreme superior gaze D Slight amount of lid lag when moving the eyes from a superior to an inferior position B Parallel movement of both eyes A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? A Perform the corneal light test, and look for symmetry of the light reflex. B Assess the individual's near vision. C Perform the confrontation test. D Observe the distance between the palpebral fissures. D Observe the distance between the palpebral fissures. When examining the ear with an otoscope, how should the tympanic membrane look? A Whitish with black flecks or dots B Light pink with a slight bulge C Pearly gray and slightly concave D Pulled in at the base of the cone of light C Pearly gray and slightly concave The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? A Finer and less prominent nasal hair B Decreased ability to identify odors C Hypertrophy of the gums D Increased production of saliva B Decreased ability to identify odors During ocular examinations, what should the nurse keep in mind regarding the movement of the extraocular muscles? A Is stimulated by CNs III, IV, and VI. B Is stimulated by cranial nerves (CNs) I and II. C Is impaired in a patient with cataracts. D Is decreased in the older adult. A Is stimulated by CNs III, IV, and VI. In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings? A Continue with the assessment, looking for any other abnormal findings. B Obtain a throat culture on the patient for possible streptococcal (strep) infection. C Refer the patient to a throat specialist. D No response is needed; this appearance is normal for the tonsils. D No response is needed; this appearance is normal for the tonsils. Complete neurologic examination in order: Mental status Cranial nerves Motor system Sensory system Reflexes Mental status exam: ABCT Appearance Behavior Cognition Thought process Cranial Nerves: I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Accessory XII. Hypoglossal Motor system: Fine motor skills- RAM, finger to finer, finger to nose, heel to shin. Gross motor skills- Gait, heel to toe, heel walk, balance on 1 foot, Romberg/swaying test Sensory system: Sharp/dull sensation, point location, light touch. Reflexes: Biceps- Upper arm Triceps- Back of arm above elbow Brachioradialis- 2-3 cm from wrist Patellar - Below kneecap Achilles- Above heel of foot (Foot should flex, toes go up) Plantar/Babinski- Bottom of foot (Plantar flex and toes should curl) Positive babinski sign: ABNORMAL - dorsiflexion of big toe and fanning of all toes; occurs with upper motor neuron disease of the corticospinal tract; NORMAL IN INFANTS negative babinski sign: NORMAL - plantar flexion and curling of toes with flexion of forefoot. Signs/symptoms of acute pain: Guarding, grimacing, vocalizations such as moaning, agitation, restlessness, difficulty concentration, diaphoresis, increased BP and pulse. Signs and symptoms of chronic pain: Bracing, rubbing, diminished activity, sighing, and change in appetite. Dysphonia: Difficulty/discomfort producing speech sounds, usually due to hoarseness. Dysarthria: Difficulty forming words. (Articulation) Dysphasia: Difficulty with language comprehension or expression. Aphasia: Inability to speak or write. What tests are used to look at a patient's visual acuity? Snellen and Jaegar - CN II Optic What test is used to assess a patient's visual field? Confrontation - CN II Optic How far do should the nurse stand behind the patient when assessing CN 8? A 1-2 ft B 2-3 ft C 4-5 ft D 6 ft A 1-2 ft How far should the nurse stand in front of the patient when performing the corneal light reflex/hirshberg test? A 6 ft B 4 ft C 3 ft D 1 ft D 1 ft How far should the nurse stand in front of the patient when performing the diagnostic position/cardinal direction test? A 2 ft B 1 ft C 6 ft D 3 ft B 1 ft How far should the nurse stand in front of the patient when performing the peripheral/confrontation test? A 3 ft B 5 ft C 6 ft D 2 ft D 2 ft Presbyopia: Impaired near vision in middle age or older caused by loss of elasticity in the lens NORMAL IN ELDERLY PATIENT Myopia: Nearsightedness (Cannot see far away) Hyperopia: Farsightedness (Cannot see close up) Normal pupil size in adults: 3-5 mm in diameter Myosis: Pupils 3 mm in diameter Mydriasis: Pupils 5 mm in diameter Anisocoria: A condition in which the pupils are different sizes Nystagmus: Jittering of the eyes Strabismus: Crossing of the eyes Weber test Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. (Tune should be heard equally in both ears.) Rinne test Hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction. BONE CONDUCTION IS TWICE AS LONG AS AIR CONDUCTION!!!!!! Conductive hearing loss: Hearing impairment caused by interference with sound or vibratory energy in the external canal, middle ear, or ossicles. Caused by otosclerosis, drainage, ear infection, busted eardrum, impacted cerumen, or trauma. Sensorineural hearing loss: The most common form of hearing loss (issues with inner ear) caused by damage to CN 8, prebycusis, or chronic use of NSAIDS. Where should the nurse assess the parotid gland? In front of the ear with patient's head extended. What technique is used to palpate the lymph nodes? Gentle pressure, with 4 finger pads, circular motions. (Assess bilaterally and compare symmetrically) Should the nurse feel lymph nodes on a healthy patient? A Yes B No B No If lymph nodes ARE felt, what should they feel like? If lymph nodes are healthy, they will feel discreet, moveable, soft, and non-tender. TRUE OR FALSE? Infections lumps are bilateral and should feel firm, large, and moveable. TRUE TRUE OR FALSE? Cancerous lumps are unilateral and should feel non-moveable and hard/solid. TRUE TRUE OR FALSE? You can feel a healthy patient's thyroid. FALSE What should a bruit sound like? A blowing, swooshing, whooshing, pulsulate sound. What is the cone of light in the left ear? A. 1 o'clock B 2 o'clock C 7 o'clock D 5 o'clock C 7 o'clock What is the cone of light in the right ear? A.1 o'clock B 2 o'clock C 7 o'clock D 5 o'clock D 5 o'clock The physician reports that a patient with a neck tumor has a tracheal shift. The nurse should understand that what is occurring to the patient's trachea? A Pulled downward in a rhythmic pattern B Pushed downward C Pushed to the unaffected side D Pulled to the affected side C Pushed to the unaffected side The nurse is testing a patient's visual accommodation. How is accommodation assessed? A Pupillary constriction when looking at a near object B Pupillary dilation when looking at a distant object C Changes in peripheral vision in response to bright light D Involuntary blinking in the presence of bright light A Pupillary constriction when looking at a near object A patient's vision is recorded as 20/80 in each eye. How does the nurse interpret this finding? A Patient has acute vision. B Patient has presbyopia. C Patient has normal vision. D Patient as poor vision. D Patient as poor vision. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? A Keeping the speculum tip medial to avoid touching the floor of the nares B Avoiding touching the nasal septum with the speculum C Inserting the speculum at least 3 cm into the vestibule D Gently displacing the nose to the side that is being examined B Avoiding touching the nasal septum with the speculum During an oral examination of a 4-year-old Indigenous American child, the nurse notices that her uvula is partially split. Which of these statements is accurate? A This condition is a cleft palate and is common in Indigenous American B This condition is due to an injury and should be reported to the authorities. C A bifid uvula may occur in some Indigenous American groups. D A bifid uvula is torus palatinus, which frequently occurs in Indigenous American. C A bifid uvula may occur in some Indigenous American groups Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? A Dark retinal background B Increased photosensitivity C Increased night vision D Narrowed palpebral fissures A Dark retinal background In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. Based on this finding, what should the nurse do? A Continue with the ophthalmoscopic examination, and refer the patient for further evaluation. B Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. C Check the light source of the ophthalmoscope to verify that it is functioning. D Suspect that an opacity is present in the lens or cornea. B Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. A patient's vision is recorded as 20/30 when the Snellen eye chart is used. How should the nurse interpret these results? A At 30 feet the patient can read the entire chart. B The patient can read from 30 feet what a person with normal vision can read from 20 feet. C The patient can read at 20 feet what a person with normal vision can read at 30 feet. D The patient can read the chart from 20 feet in the O.S. and 30 feet in the O.D. C The patient can read at 20 feet what a person with normal vision can read at 30 feet. During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky, white cerumen in his canal. What is the significance of this finding? A It could be indicative of change in cilia; the nurse should assess for hearing loss. B It represents poor hygiene. C It is a normal finding, and no further follow-up is necessary. D It is probably the result of lesions from eczema in his ear. C It is a normal finding, and no further follow-up is necessary. 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 trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. C The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. 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. When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? A Teeth appearing shorter B Tongue that looks smoother in appearance C Buccal mucosa that is beefy red in appearance D Small, painless lump on the dorsum of the tongue B Tongue that looks smoother in appearance A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? A Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. B Shorten the distance between the patient and the chart until the letters are seen, and record that distance. C Refer the patient to an ophthalmologist or optometrist for further evaluation. D Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. B Shorten the distance between the patient and the chart until the letters are seen, and record that distance. When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. What does the nurse understand about this assessment finding? A It may indicate a problem with extraocular muscles. B It indicates increased intraocular pressure. C It is expected. D It may result in problems with tearing. C It is expected. The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. What should the nurse expect to find upon examination? A Annular lesions that have grown together B Lesions that are grouped or clustered together C Lesions that run together D Lesions arranged in a line along a nerve route C Lesions that run together A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and is prescribed oral hypoglycemic agents. What should the nurse include in this patient's teaching? A Increased possibility of bruising B Skin sensitivity as a result of exposure to salt water C Lack of availability of glucose-monitoring equipment D Importance of sunscreen and avoiding direct sunlight D Importance of sunscreen and avoiding direct sunlight A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? A Nonsteroidal anti-inflammatory drugs for pain B Tetracyclines for acne C Proton pump inhibitors for heartburn D Thyroid replacement hormone for hypothyroidism B Tetracyclines for acne While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? A Peripheral arterial insufficiency B Heart failure C Local inflammation D Venous stasis B Heart failure The nurse is preparing for a certification course on skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? (Select all that apply.) Papule: Hypertrophic scar. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus). Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color. Vesicle: Known as a friction blister. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color. Vesicle: Known as a friction blister. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm. A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. What is the best response by the nurse? A "Fiery red, star-shaped marking on the cheek that has a solid circular center." B "Confluent and extensive patch of petechiae and ecchymoses on the feet." C "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." D "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color." B "Confluent and extensive patch of petechiae and ecchymoses on the feet." The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? A Lesion of sensory cortex B Peripheral neuropathy C Hyperalgesia D Hyperesthesia B Peripheral neuropathy The nurse is performing an oral assessment on a 40-year-old black patient and notices the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true about this lesion? A It is indicative of cancer and should be immediately tested. B It is the result of hyperpigmentation and is a normal finding. C It is torus palatinus and would normally be found only in smokers. D It is leukoedema which is common in dark-pigmented people. D It is leukoedema which is common in dark-pigmented people. An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? A White patches on the mucous membranes B Dry mucous membranes and cracked lips C Smooth mucous membranes and lips D Pale mucous membranes B Dry mucous membranes and cracked lips A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" Which is the best response by the nurse? A "They are signs of decreased hematocrit r/t anemia." B "Those are due to the destruction of melanin in your skin from exposure to the sun." C "They are clusters of melanocytes that appear after extensive exposure to sunlight." D "Those are areas of hyperpigmentation r/t decreased perfusion and vasoconstriction." C "They are clusters of melanocytes that appear after extensive exposure to sunlight." The nurse is assessing for clubbing of the fingernails. Which is the best description of clubbing? A Nail bases that feel spongy with an angle of the nail base of 150 degrees B Curved nails with a convex profile and ridges across the nails C Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy D Nail bases that are firm and slightly tender C Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? A Severe obesity B Severe dehydration C Childhood growth spurts D Connective tissue disorders such as scleroderma B Severe dehydration During an examination, the nurse finds that a patient has excessive dryness of the skin. How should the nurse document this finding? A Seborrhea B Xerosis C Pruritus D Alopecia B Xerosis A patient comes in for a physical examination in late July and states that she was "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool. What should the nurse understand is the likely cause? A Peripheral vasodilation B Peripheral vasoconstriction C Venous pooling D Decreased arterial perfusion B Peripheral vasoconstriction A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? A Glasgow Coma Scale B Complete neurologic examination C Screening neurologic examination D Neurologic recheck examination B Complete neurologic examination A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. Why is it important that the nurse encourage her to stop trying to remove the corn with scissors? A With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. B She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. C With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely. D The woman could be at increased risk for infection and lesions because of her chronic disease. D The woman could be at increased risk for infection and lesions because of her chronic disease. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be r/t which factor in the older adult? A An increased loss of elastin and a decrease in subcutaneous fat B An increase in elastin and a decrease in subcutaneous fat C Increased vascularity of the skin D Increased numbers of sweat and sebaceous glands A An increased loss of elastin and a decrease in subcutaneous fat A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? A Diameter of less than 6 mm B Color variation C Symmetry of lesions D Border regularity B Color variation The nurse is assessing a patient with liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? A Yellow color of the sclera that extends up to the iris B Skin that appears yellow when examined under low light C Yellow deposits on the palms and soles of the feet where jaundice first appears D Yellow patches in the outer sclera A Yellow color of the sclera that extends up to the iris During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. How should the nurse interpret these findings? A Demyelination of nerves attributable to a lesion B Lesion in the cerebral cortex C Normal changes attributable to aging D CNS dysfunction C Normal changes attributable to aging The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. How should the nurse interpret these findings? A Clonus, which is a hyperactive response B Positive Babinski sign, which is abnormal for adults C Achilles reflex, which is an expected response D Negative Babinski sign, which is normal for adults B Positive Babinski sign, which is abnormal for adults During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are white. From these findings, what can the nurse rule out? A Cyanosis B Pallor C Iron deficiency D Jaundice D Jaundice The nurse keeps in mind that a thorough skin assessment is extremely important. What can the skin provide important information about? A Socioeconomic status B Support systems C Psychological wellness D Circulatory status D Circulatory status The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? A Palpating for tenderness and local areas of ecchymosis B Palpating the skin for edema and increased warmth C Assessing the oral mucosa for generalized erythema D Assessing the skin for cyanosis and swelling B Palpating the skin for edema and increased warmth During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? A 1+ B 2+ C 3+ D4+ B 2+ A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? (Select all that apply.) Open blister areas have a red-pink wound bed. Localized redness in light skin will blanch with fingertip pressure. Intact skin appears red but is not broken. Partial thickness skin erosion is observed with a loss of epidermis or dermis. Patches of eschar cover parts of the wound. Ulcer extends into the subcutaneous tissue. Open blister areas have a red-pink wound bed. Partial thickness skin erosion is observed with a loss of epidermis or dermis. During the aging process, the hair can look gray or white and begin to feel thin and fine. What should the nurse understand causes this? A Increased adipose tissue B Decrease in the number of functioning melanocytes C Decrease in the number of functioning phagocytes D Increase in the vascularity of the scalp B Decrease in the number of functioning melanocytes A patient has had a "terrible itch" for several months that he has been continuously scratching. What might the nurse expect to find upon physical examination? A Keratosis B Keloid C Fissure D Lichenification D Lichenification During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? A Hypotonic muscles as a result of total relaxation. B Mild, even resistance to mo