Jarvis 28

Which part of the body should the nurse examine to assess Cranial nerve VII?
A. Eye
B. Face
C. Mouth
D. Throat
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Terms in this set (24)
Which part of the body should the nurse examine to assess Cranial nerve VII?
A. Eye
B. Face
C. Mouth
D. Throat
B
Which assessment includes size, shape and strength parameters? A. Breast examination
B. Abdominal examination
C. Cardiovascular examination
D. Musculoskeletal examination
D
While examining the eyes, the nurse finds that the patient has 20/20 vision, symmetric corneal reflex, and white sclera. The patient's pupil size is 3 mm while resting and 2 mm while constricting. What does the nurse infer from these findings?
A. The patient has ptosis
B. The patient has strabismus
C. The patient has nystagmus
D. The patient has normal vision
D
The nurse finds a positive Babinski reflex in an adult during a physical assessment. What could be the reason for such an abnormality?
A. Neurologic impairment
B. Cardiovascular impairment
C. Musculoskeletal impairment
D. Gastrointestinal impairment
A
While collecting data, the nurse uses the Snellen chart. What does the nurse examine in the patient?A. Vision acuity
B. Stereognosis
C. Facial symmetry
D. Costovertebral angle
A
The nurse documents normocephalic as an assessment finding. What did the nurse assess in the patient?
A. Cranium
B. Abdomen
C. Optic nerve
D. Mental status
A
The student nurse is assessing the neck of a patient under the supervision of a nurse educator. Which intervention by the student nurse needs correction?
A. Palpation of the trachea in the midline
B. Palpation of the cervical lymph nodes
C. Assessment for the functioning of cranial nerve XI
D. Palpation of the carotid pulse on both sides at a time
D
While performing an oral examination, the nurse instructs the patient to say "ahh." What is the reason for giving this instruction?
A. To inspect the uvula
B. To inspect the hard palate
C. To inspect the buccal mucosa D. To inspect the teeth and gums
A
The nurse, while checking the vital signs, finds that the patient's blood pressure is decreased in the lower extremities. Which test does the nurse perform to evaluate the patient's condition?
A. Romberg test
B. Gag reflex test
C. Babinski reflex test
D. Ankle brachial index test
D
What intervention does the nurse perform to test the stereognosis of a patient?
A. Ask the patient to perform the rapid alternating movements test.
B. Ask the patient to run each heel down the shin of the opposite leg.
C. Ask the patient to extend the arms fully and touch the nose with a finger.
D. Ask the patient to identify an object placed in the hand without visual clues.
D
The health care provider has prescribed an occult blood test for a patient. Which specimen does the nurse collect for the test? A. Blood B. Urine C. Stool D. MucusCA hospitalized patient does not require a full neurologic examination during every shift assessment. What is a method of assessing the neurologic status of a patient without performing a full neurological examination? a. Palpate the carotid pulse. b. Offer the patient a glass of water. c. Look at the significant other throughout the examination. d. Assign the nursing assistant to ask the patient questions and report the findings.BThe examiner is assessing the extraocular muscles. Which of the following tests would be inappropriate? a. Confrontation test b. Corneal light reflex c. Six cardinal positions of gaze d. Cranial nerve III, IV, and VI testingAWhat should the examiner do during auscultation of breath sounds? a. Listen with the bell of the stethoscope. b. Compare sounds on the left and right sides. c. Listen only to the posterior chest for adventitious sounds. d. Instruct the patient to breathe in and out through the nose.BIn which situation should the examiner auscultate for carotid bruits? a. Middle-aged or older patient b. Pregnant patient with gestational diabetes c. Patient that reports abdominal pain d. Patient with enlarged, tender cervical lymph nodesAWhen standing with their eyes closed, feet together, and arms at their sides, a patient sways and starts to fall. How should the nurse document this finding? a. Positive Romberg sign b. Positive Babinski sign c. Positive Ortolani sign d. Positive modified Allen testAThe nurse is conducting a hearing screening. Which technique will the nurse use during the whisper test? a. The nurse pulls the pinna up and back. b. The nurse covers their lips to obscure them from view. c. The nurse asks the patient to repeat 3 letters or numbers. d. The nurse stands 4 feet away from the patient and whispers three different words.DWhen auscultating heart sounds, which technique should the nurse use? a. Listen with the bell. b. Listen with the diaphragm. c. Listen with both the diaphragm and bell working from apex to base in a Z pattern. d. Listen with both the bell and diaphragm comparing sides of the heart as progress from apex to base.BThe nurse is assessing the cranial nerves. To assess cranial nerve XII, what should the nurse ask the patient to do? a. Say "ahh". b. Stick out tongue. c. Smile and then frown. d. Follow the nurses fingers through the six cardinal positions of gaze.BWhen performing a health history, the nurse would note immunizations under which category? a. Family history b. Personal history c. Past medical history d. History of present illnessCWhile conducting a musculoskeletal assessment the nurse stands behind the patient and has the patient bend over and touch his or her toes. What is the nurse assessing? a. Balance b. The spine c. Cervical range of motion d. External rotation of hipsBThe nurse is preparing to perform an examination of the eyes. Which test will the nurse conduct to assess the patient's vision? a. Weber test b. Snellen test c. Confrontation test d. Corneal light reflexBWhich statement is true regarding the recording of data from the history and physical examination?a. Use long, descriptive sentences to document findings.b. Record the data as soon as possible after the interview and physical examination.c. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.d. If the information is not documented, then it can be assumed that it was done as a standard of care.BWhen gathering information relative to a complete health assessment, the nurse should include which in the decision-making process? (Select all that apply.)a. Treat the health assessment as a legal document.b. Use line drawings to explain and record pertinent findings.c. Do not document findings on the computer while the patient is present.d. Gather needed equipment before the start of the health assessment. e. Write down "word for word" what the patient says as evidence of reliable documentation.A,B,D