Health Assessment

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A nurse assessing the hearing of a patient w/presbycusis expects which finding on a test for hearing?
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Terms in this set (40)
A nurse assessing the hearing of a patient w/presbycusis expects which finding on a test for hearing?
air conduction will be longer than bone conduction on the rinne test. (AC>BC)
A nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of fingers and angles of the nail base greater than a straight line (exceeding 180 degree). How does the nurse document these findings?
clubbing
A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings. How will the nurse recognize the characteristics of keloids?
hypertrophic scarring extending beyond the original wound edges
A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patients left trochanter area that involves partial-thickness skin loss with damage to the sub-q tissue. The nurse reports this ulcer at what stage?
stage 2
A nurse reads in the hx that a patient has a new onset of acute otitis media. How should the nurse expect this patient's tympanic membrane to appear?
red
A nurses presentation to patients on risk for oral cancer includes which fact?
excessive consumption of alcohol
A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles and skin that is softened and broken down between the toes. What explanation does the nurse give the patient about the cause of this skin disorder?
fungal infection
A patient in the waiting room appears anxious and moves around the room cleaning surfaces with a disinfectant cloth. This behavior is consistent with which disorder?
obsessive compulsive disorder (OCD)
A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time?
document as an expected finding
A patient is put on an 1800-calorie a day diet plan. During discharge teaching the nurse explains to this patient how to use nutrition labels to determine the amount of carbs in the product. The nurse explains however that the label is based on 2000 calories. which is the appropriate formula to teach this patient of the maximum grams of carbs she can eat?
1800 calories 0.60 = 1080/4 calories/grams = 270 grams
A patient w a partial small bowel obstruction describes the pain as, "cramping, off and on pain that spreads over my stomach." what type of pain is this patient experiencing?visceral painDuring a visit to the clinic for an annual gyneclogic exam, a patient tells the nurse she had a bad experience on an airplane, "when i sat down my heart started racing, i was SOB, sweating, and i felt as if i was going to die." She stated that her husband helped her calm down after a few minutes. The nurse recognized the patient was describing which problem?panicDuring conversation, a nurse observes that the patient is talking continuously and excitedly and is switching rapidly between one topic to another with seemingly no relationship to each other. Which disorder is this describing?schizophreniaDuring the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse?Tell the patient that this represents an expected finding.How does a nurse asses movements of the eyes?assessing the cardinal fields of gazehow does the nurse perform a rinne test of hearing function?places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it.On palpation the nurse determines that the patients left thyroid lobe is larger than the right, what is the nurse's most appropriate action at this time?refer the patient to the healthcare provider for further evaluationWhat findings does a nurse expect when inspecting and palpating a patients nails?Nail surface is smooth and roundedwhen palpating the right lobe of the patients thyroid gland using the interior approach the nurse feels the tissue between which two structures?sternocleidomastoid muscle and the tracheaWhich tool is the best choice for a nurse to use as a quick screening tool to asses a patient's dietary intake?24 hour recallA nurse asks the patient to stand w feet together, arms resting at the sides, eyes open, then closed. Which response by the patient indicates an expected cerebellar function?sways slightly and maintains upright posture w feet togetherA nurse determines that a patient has a heart rate of 42 BPM, what might be a cause of this heart rate?SA node failureA nurse had previously heard crackles over both lungs of a patient, as a patient improves, what lung sounds does the nurse expect to hear in the patient's lungs?vesicular breath sounds heard in peripheral lung fieldsThe nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration, what action can the nurse take to ensure this is an accurate finding?hold stethoscope firmly to prevent movement when placed over chest haira patient has a herniated disc compressing the lumbar spine at L2, L3, and L4 that is impairing deep tendon reflexed. which response does a nurse expect from this patient?diminished contraction of the quadriceps muscle w extension of the lower lega patient reports having difficulty swallowing. based on this info, how does the nurse assess the cranial nerve related to swallowing?observe the rising of the soft pallet when the patient says, "aahhhhhhh"a patient reports that he as coronary artery disease w ventricle hypertrophy. based on this data, what finding should the nurse expect during assessment?S4 heart soundOn inspection of a patient's hands, the nurse notices ulnar deviation and swan-neck deformities bilaterally and correlates this finding with which disorder?Rheumatoid arthritisThe nurse is comparing pitch and duration of the various types of a patient's breath sounds and recognizes which as an expected finding?bronchovesicual sounds have a moderate pitch and a 1:1 expository v. inspiratory ratioWhat is the earliest and most sensitive indication of altered cerebral function?change in level of consciousnesswhat sounds does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patientno soundwhat technique does the nurse use to test the patellar deep tendon reflex?ask the patient to flex one knee to 90 degrees while the nurse strikes the appropriate tendon in the knee w the blunt end of the reflex hammerwhen a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion?external rotation and abduction of the shoulderwhen assessing an adults liver the nurse percusses the lower border and finds it to be 5 cm below the costal margin. what is the nurse's appropriate action?percuss downward beginning in the right-mid clavicular linewhen assessing the neck of a healthy adult, the nurse expects which findings?turning the chin to the right shoulder, then the left shoulderwhen inspecting a patients abdomen, the nurse notes which finding as abnormal?marked widely lateral pulsating mass to the left of the mid linewhich quadrant does a nurse select when palpating a patients liver?right upper quadrantwhich patient should the nurse assess first?the patient whose respiratory rate is 26 breaths/min and whose trachea deviates to the rightwhich question will give the nurse additional info about the nature of the patient's dyspnea?how has this condition affected your day-to-day activities?which techniques does a nurse use to palpate a patient's right kidney?ask the patient to take a deep breath, elevate the right flank w left hand, and deeply palpate for the right kidney w the right hand