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Exam VII studyguide

Health Assessment

The patient complains of "seeing double". The RN documents this as: diplopia
A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: conduct vibrations of sounds to the inner ear.
Interpret the findings of a vision examination recorded as 20/20 OU: The patient has normal vision in both eyes.
Which of the following statements is true concerning air conduction? It is the most efficient pathway for hearing.
A 92-year-old patient is admitted to the emergency room. The right side of his face is droopy. You suspect a possible stroke. You therefore suspect the patient may also experience which of the following? Dysphagia
A semiconscious woman is brought to the ER after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: Carbon monoxide poisoning.
During an examination, the nurse finds that a patient has excess dryness of the skin. The best term to describe this condition is: xerosis
Accommodation refers to: pupillary constriction when looking at a near object.
A flat, non-palpable discolored lesion, which is less than 1 cm is noted. It should be described as a: macule
PERRLA stands for: Pupils equal, round, reactive to light and accomodation.
The Rinne test has been administered to a patient. A normal response is a positive Rinne test. This should be documented as: AC > BC.
Impacted cerumen is a common cause of: conductive hearing loss.
A patient with emphysema and chronic bronchitis has come to the clinic for a skin assessment. You might expect to find which of the following: Clubbing of the nails.
The nurse notes the presence of periorbital edema when performing an eye assessment on an elderly patient. The nurse will: ask the patient if they have a history of heart failure.
A patient is noted to be experiencing profuse perspiration. This is documented as: diaphoresis
A thorough skin assessment is very important because the skin holds information about: circulatory status
The nurse just noted from a patient's medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find: lesions that run together.
In the aging population the most common causes of decreased visual functioning include all of the following EXCEPT: arcus senilis.
You are obtaining a medical history on a newly admitted patient. Which of the following clues noted during conversation would indicate to you that the patient has possible hearing loss? During conversation, the patient is watching your lips closely rather than your eyes.
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: stimulated by cranial nerves III, IV, and VI.
Another name for a mole is: nevus
When the skin is exposed to ultraviolet light, which of the following beneficial substances is produced? Vitamin D.
70 yr old w/history of hypertension & coronary artery disease; presence of pitting edema in lower legs bilaterally. Skin puffy, tight, normal color. No increased redness or tenderness over lower legs & peripheral pulses = & strong. Likely cause of edema? Heart failure.
A patient presents with complaints of a painful rash. The rash includes small grouped vesicles, some of which are crusted. They are arranged in a linear pattern which extends around the trunk on the right side, just below the axilla. You suspect: herpes zoster.
A patient comes in for a physical, and she complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: peripheral vasoconstriction.
In performing a voice test to assess hearing, which of the following would you do? Whisper two-syllable words and ask the patient to repeat them.
The ABCDEs of moles stands for: asymmetry, border, color, diameter, enlargement
When performing an otoscopic examination on an adult, which of the following is true? You pull the pinna up and back before inserting the speculum.
A patient has been confined to her recliner chair since early in the day with her feet down. During your evaluation of her lower extremities you might expect to find: edema
A patient complains of constant ringing, crackling, and buzzing sounds in their ears. This should be documented as: tinnitus
The nurse is bathing a 76 year old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to: an increased loss of elastin and a decrease in subcutaneous fat in the elderly.
The student nurse is administering 2 eye drops in the patient's right eye. This is documented as: OD
The patient remarks to the RN, "I've been having trouble with my hearing. So, why did the doctor ask me about what medications I take?" The RN's best response would be: "Some medications are ototoxic, meaning they can affect your hearing."
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. She needs to be concerned about which of the following? the importance of sunscreen and avoiding direct sunlight.
When assessing the pupillary light reflex, the nurse should use which technique? shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.
A patients surgical scar has healed. Assessment of the scar reveals an elevated rubbery-like texture which is excessive in size. This is called a/an: keloid
Which of the following best describes the test the nurse should use to assess the function of cranial nerve X? ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.
An elderly patient is noted to have significant edema of the lower extremities. The nurse should review which of the following labs? Albumin
The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of the following conditions? in an individual who is severely dehydrated.
The RN is performing a Weber test. Correct technique includes: placing a vibrating tuning fork at the top and in the midline of the person's skull.
A few days after a summer hiking trip, a 25 year old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: Lyme disease.
The mother of a 2 year old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of the following in the teaching plan? the purpose of the tubes is to decrease the pressure and allow for drainage.
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of the following would be included in the module? the epidermis is replaced every 4 weeks.
68 yr old woman; having trouble w/reading paper, sewing, & even seeing faces of her grandchildren. On examination, you note that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: she may have macular degeneration.
A patient has been diagnosed with strep throat. The nurse is aware that without treatment which complication may occur? rheumatic fever.
During a check-up, a 22 year old female patient tells the nurse that she uses an over counter nasal spray because of her allergies. She also notes that it doesn't work as well as it used to when she started using it. Best response by the nurse would be: "Using these nasal medications irritates the lining of the nose and may cause rebound swelling."
Checking for skin temperature is best accomplished by using the: Dorsal surface of the hands.
The part of the ear which contains the sensory organs for equilibrium is the: inner ear.
A patient complains of sensitivity and pain in the eyes when exposed to bright lights. The RN can document this as: photophobia
You are preparing to assess the visual acuity of a patient. How would you proceed? Use the Snellen chart positioned 20 feet away from the patient.
Created by: chaptravelman