Health Assessment Final Test Bank Questions

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:

a. Objective

b. Reflective

c. Subjective

d. Introspective

a. Objective

Rationale: Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data.

A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:

a. Objective

b. Reflective

c. Subjective

d. Introspective

c. Subjective

Rationale: Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data.

When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to:

a. Immediately notify the patients physician

b. Document the sound exactly as it was heard

c. Validate the data by asking a coworker to listen to the breath sounds

d. Assess again in 20 minutes to note whether the sound is still present

c. Validate the data by asking a coworker to listen to the breath sounds

Rationale: When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.

The patients record, laboratory studies, objective data, and subjective data combine to form the:

a. Data base

b. Admitting data

c. Financial statement

d. Discharge summary

a. Data base

Rationale: Together with the patients record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patients record, laboratory studies, or data.

The nursing process is a sequential method of problem solving that nurses use and includes which steps?

a. Assessment, treatment, planning, evaluation, discharge, and follow-up

b. Admission, assessment, diagnosis, treatment, and discharge planning

c. Admission, diagnosis, treatment, evaluation, and discharge planning

d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

Rationale: The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

Barriers to incorporating EBP include:

a. Nurses lack of research skills in evaluating the quality of research studies

b. Lack of significant research studies

c. Insufficient clinical skills of nurses

d. Inadequate physical assessment skills

a. Nurses lack of research skills in evaluating the quality of research studies

Rationale: As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers.

The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.

a. Inspiratory wheezes noted in left lower lobes

b. Hypoactive bowel sounds

c. Nonproductive cough

d. Edema, +2, noted on left hand

e. Patient reports dyspnea upon exertion

f. Rate of respirations 16 breaths per minute

a. Inspiratory wheezes noted in left lower lobes

c. Nonproductive cough

e. Patient reports dyspnea upon exertion

f. Rate of respirations 16 breaths per minute

Rationale: Clustering related cues help the nurse recognize relationships among the data. The cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are not related to the respiratory cues.

The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply.

a. Open-ended questions elicit cold facts

b. They allow for self-expression

c. Open-ended questions build and enhance rapport

d. They leave interactions neutral

e. Open-ended questions call for short one- to two-word answers

f. They are used when narrative information is needed

b. They allow for self-expression

c. Open-ended questions build and enhance rapport

f. They are used when narrative information is needed

Rationale: Open-ended questions allow for self-expression, build and enhance rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.

The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation? Select all that apply.

a. Collect the patients data in a direct, face-to-face manner.

b. Enter all the data as the patient states them.

c. Ask the patient to wait as the nurse enters the data.

d. Type the data into the computer after the narrative is fully explored.

e. Allow the patient to see the monitor during typing.

a. Collect the patients data in a direct, face-to-face manner.

d. Type the data into the computer after the narrative is fully explored.

e. Allow the patient to see the monitor during typing.

Rationale: The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patients narrative story in a direct, face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.

During an interview, the nurse would expect that most of the interview will take place at what distance?

a. Intimate zone

b. Personal distance

c. Social distance

d. Public distance

c. Social distance

Rationale: Social distance, 4 to 12 feet, is usually the distance category for most of the interview. Public distance, over 12 feet, is too much distance; the intimate zone is inappropriate, and the personal distance will be used for the physical assessment.

During the interview portion of data collection, the nurse collects __________ data.

a. Physical

b. Historical

c. Objective

d. Subjective

d. Subjective

Rationale: The interview is the first, and really the most important, part of data collection. During the interview, the nurse collects subjective data; that is, what the person says about him or herself.

During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why haven't you taken your insulin? Which statement is an appropriate evaluation of this question?

a. This question may place the patient on the defensive.

b. This question is an innocent search for information.

c. Discussing his behavior with his wife would have been better.

d. A direct question is the best way to discover the reasons for his behavior.

a. This question may place the patient on the defensive.

Rationale: The adults use of why questions usually implies blame and condemnation and places the person on the defensive. The other statements are not correct.

The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?

a. Determine the communication method he prefers.

b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading.

c. Request a sign language interpreter before meeting with him to help facilitate the communication.

d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.

a. Determine the communication method he prefers.

Rationale: The nurse should ask the deaf person the preferred way to communicate by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him squarely and have good lighting on the nurses face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and supplement his or her voice with appropriate hand gestures or pantomime.

A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this?

a. An aged person has a longer story to tell.

b. An aged person is usually lonely and likes to have someone with whom to talk.

c. Aged persons lose much of their mental abilities and require longer time to complete an interview.

d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said.

a. An aged person has a longer story to tell.

Rationale: The interview usually takes longer with older adults because they have a longer story to tell. It is not necessarily true that all older adults are lonely, have lost mental abilities, or are hard of hearing.

During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the child's full cooperation?

a. Tell the child that the blood pressure cuff is going to give her arm a big hug.

b. Tell the child that the blood pressure cuff is asleep and cannot wake up.

c. Give the blood pressure cuff a name and refer to it by this name during the assessment.

d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

Rationale: Take the time to give a short, simple explanation with a concrete explanation for any unfamiliar equipment that will be used on the child. Preschoolers are animistic; they imagine inanimate objects can come alive and have human characteristics. Thus a blood pressure cuff can wake up and bite or pinch.

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?

a. To provide an opportunity for interaction between the patient and the nurse

b. To provide a form for obtaining the patients biographic information

c. To document the normal and abnormal findings of a physical assessment

d. To provide a database of subjective information about the patients past and current health

d. To provide a database of subjective information about the patients past and current health

Rationale: The purpose of the health history is to collect subjective data, which is what the person says about him or herself. The other options are not correct.

What are the four main components of the mental status assessment?

1. appearance

2. behavior

3. cognition

4. thought processes

Think of the initials A, B, C, and T to help remember these categories.

When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?

a. Family history

b. Review of systems

c. Functional assessment

d. Reason for seeking care

c. Functional assessment

Rationale: Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care.

During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating?

a. The patient is an alcoholic.

b. The patient is annoyed at the questions.

c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms.

d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

Rationale: The CAGE test is known as the cut down, annoyed, guilty, and eye-opener test. If a person answers yes to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment.

The nurse is assessing a patients headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply.

a. Where is the headache pain?

b. Did you have these headaches as a child?

c. On a scale of 1 to 10, how bad is the pain?

d. How often do the headaches occur?

e. What makes the headaches feel better?

f. Do you have any family history of headaches?

a. Where is the headache pain?

c. On a scale of 1 to 10, how bad is the pain?

d. How often do the headaches occur?

e. What makes the headaches feel better?

Rationale: The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed: (1) P: provocative or palliative; (2) Q: quality or quantity; (3) R: region or radiation; (4) S: severity scale; (5) T: timing; and (6) U: understand the patients perception. Asking, Where is the pain? reflects region. Asking the patient to rate the pain on a 1 to 10 scale reflects severity. Asking How often reflects timing. Asking what makes the pain better reflects provocative. The other options reflect health history and family history.

The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply.

a. How much junk food does your child eat?

b. How many teeth has he lost, and when did he lose them?

c. Is he able to tie his shoelaces?

d. Does he take a childrens vitamin?

e. Can he tell time?

f. Does he have any food allergies?

b. How many teeth has he lost, and when did he lose them?

c. Is he able to tie his shoelaces?

e. Can he tell time?

Rationale: Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.

A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms?

a. It is a sharp, burning pain in my stomach.

b. I also have the sweats and nausea when I feel this pain.

c. I think this pain is telling me that something bad is wrong with me.

d. This pain happens every time I sit down to use the computer.

d. This pain happens every time I sit down to use the computer.

Rationale: The setting describes where the person is or what the person is doing when the symptom starts. Describing the pain as sharp and burning reflects the character or quality of the pain; stating that the pain is telling the patient that something bad is wrong with him reflects the patients perception of the pain; and describing the sweats and nausea reflects associated factors that occur with the pain.

During an examination, the nurse can assess mental status by which activity?

a. Examining the patients electroencephalogram

b. Observing the patient as he or she performs an intelligence quotient (IQ) test

c. Observing the patient and inferring health or dysfunction

d. Examining the patients response to a specific set of questions

c. Observing the patient and inferring health or dysfunction

Rationale: Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individuals behaviors, such as consciousness, language, mood and affect, and other aspects.

The nurse is assessing the mental status of a child. Which statement about children and mental status is true?

a. All aspects of mental status in children are interdependent.

b. Children are highly labile and unstable until the age of 2 years.

c. Children's mental status is largely a function of their parents level of functioning until the age of 7 years.

d. A child's mental status is impossible to assess until the child develops the ability to concentrate.

a. All aspects of mental status in children are interdependent.

Rationale: Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mothers body. The other statements are not true.

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. The nurses best approach regarding this examination is to:

a. Plan to defer the rest of the mental status examination.

b. Skip the language portion of the examination, and proceed onto assessing mood and affect.

c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time.

d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

a. Plan to defer the rest of the mental status examination.

Rationale: In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?

a. A patients family is the best resource for information about the patients coping skills.

b. Gathering mental status information during the health history interview is usually sufficient.

c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time.

d. To get a good idea of the patients level of functioning, performing a complete mental status examination is usually necessary.

b. Gathering mental status information during the health history interview is usually sufficient.

Rationale: The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.

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. During the tests of cognitive function, the nurse would expect that he:

a. May display some disruption in thought content.

b. Will state, I am so relieved to be out of intensive care.

c. Will be oriented to place and person, but the patient may not be certain of the date.

d. May show evidence of some clouding of his level of consciousness.

c. Will be oriented to place and person, but the patient may not be certain of the date.

Rationale: The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, Some people have trouble keeping up with the dates while in the hospital. Do you know todays date? Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patients level of consciousness would be:

a. Lethargic

b. Obtunded

c. Stuporous

d. Semialert

a. Lethargic

Rationale: Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased. (See Table 5-3 for the definitions of the other terms.)

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, I buy obie get spirding and take my train. What is the best description of this patients problem?

a. Global aphasia

b. Brocas aphasia

c. Echolalia

d. Wernicke's aphasia

d. Wernicke's aphasia

Rationale: This type of communication illustrates Wernicke's or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another persons words or phrases. (See Table 5-4 for the definitions of the other disorders.)

A patient repeatedly seems to have difficulty coming up with a word. He says, I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs. The nurse will note on his chart that he is using or experiencing:

a. Blocking

b. Neologism

c. Circumlocution

d. Circumstantiality

c. Circumlocution

Rationale: Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:

a. Confusion

b. Ambivalence

c. Depersonalization

d. Inappropriate affect

d. Inappropriate affect

Rationale: An inappropriate affect is an affect clearly discordant with the content of the persons speech. (See Table 5-5 for the definitions of the other terms.)

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. For the mental status examination, the nurse should first assess the patients:

a. Affect and mood

b. Memory and affect

c. Language abilities

d. Level of consciousness and cognitive abilities

d. Level of consciousness and cognitive abilities

Rationale: Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an alteration in mood, affect, or language abilities.

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

a. Mental status assessment diagnoses specific psychiatric disorders.

b. Mental disorders occur in response to everyday life stressors.

c. Mental status functioning is inferred through the assessment of an individuals behaviors.

d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

c. Mental status functioning is inferred through the assessment of an individuals behaviors.

Rationale: Mental status functioning is inferred through the assessment of an individuals behaviors. It cannot be directly assessed like the characteristics of the skin or heart sounds.

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?

a. Please count backward from 100 by seven.

b. I will name three items and ask you to repeat them in a few minutes.

c. Please point to articles in the room and parts of the body as I name them.

d. What would you do if you found a stamped, addressed envelope on the sidewalk?

c. Please point to articles in the room and parts of the body as I name them.

Rationale: Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing (asking the person to make up and write a sentence).

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 nurses best response in this situation?

a. Do you have a weapon?

b. How do other people treat you?

c. Are you feeling so hopeless that you feel like hurting yourself now?

d. People often feel hopeless, but the feelings resolve within a few weeks.

c. Are you feeling so hopeless that you feel like hurting yourself now?

Rationale: When the person expresses feelings of hopelessness, despair, or grief, assessing the risk of physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions.

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia?

a. Global

b. Brocas

c. Dysphonic

d. Wernicke's

a. Global

Rationale: Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. (Brocas aphasia and Wernickes aphasia are described in Table 5-4.) Dysphonic aphasia is not a valid condition.

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply.

a. Develops over a short period.

b. Person is experiencing apraxia.

c. Person is exhibiting memory impairment or deficits.

d. Occurs as a result of a medical condition, such as systemic infection.

e. Person is experiencing agnosia.

a. Develops over a short period.

c. Person is exhibiting memory impairment or deficits.

d. Occurs as a result of a medical condition, such as systemic infection.

Rationale: Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia.

The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the nurse looks for cardiac problems that are associated with chronic use of alcohol, such as:

a. Hypertension.

b. Ventricular fibrillation.

c. Bradycardia.

d. Mitral valve prolapse.

a. Hypertension.

Rationale: Even moderate drinking leads to hypertension and cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinning. Ventricular fibrillation, bradycardia, and mitral valve prolapse are not associated with chronic heavy use of alcohol.

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. Record the results of the assessment, and notify the physician on call.

b. State, You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm willing to help you.

c. State, It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter.

d. Give the patient information about a local rehabilitation clinic.

b. State, You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm willing to help you.

Rationale: If an assessment has determined that the patient has at-risk drinking behavior, then the nurse should give a short but clear statement of assistance and concern. Simply giving out a telephone number or referral to agencies may not be enough.

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? The person:

a. Has a physiologic dependence on a substance.

b. Requires an increased amount of the substance to produce the same effect.

c. Requires daily use of the substance to function and is unable to stop using it.

d. Experiences a syndrome of physiologic symptoms if the substance is not used.

b. Requires an increased amount of the substance to produce the same effect.

Rationale: The concept of tolerance to a substance indicates that the person requires an increased amount of the substance to produce the same effect. Abuse indicates that the person needs to use the substance daily to function, and the person is unable to stop using it. Dependence is an actual physiologic dependence on the substance. Withdrawal occurs when cessation of the substance produces a syndrome of physiologic symptoms.

A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? Select all that apply.

a. Bradycardia

b. Coarse tremor of the hands

c. Transient hallucinations

d. Somnolence

e. Sweating

b. Coarse tremor of the hands

c. Transient hallucinations

e. Sweating

Rationale: Symptoms of uncomplicated alcohol withdrawal start shortly after the cessation of drinking, peak at the second day, and improve by the fourth or fifth day. Symptoms include coarse tremors of the hands, tongue, and eyelids; anorexia; nausea and vomiting; autonomic hyperactivity (e.g., tachycardia, sweating, elevated blood pressure); and transient hallucinations, among other symptoms (see Table 6-7).

A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop cold turkey. He asks the nurse, What symptoms can I expect if I do this? Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? Select all that apply.

a. Headaches

b. Hunger

c. Sleepiness

d. Restlessness

e. Nervousness

f. Sweating

a. Headaches

b. Hunger

d. Restlessness

e. Nervousness

Rationale: Symptoms of nicotine withdrawal include vasodilation, headaches, anger, irritability, frustration, anxiety, nervousness, awakening at night, difficulty concentrating, depression, hunger, impatience, and the desire to smoke (see Table 6-7).

The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature?

a. Fingertips; they are more sensitive to small changes in temperature.

b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.

c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.

d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.

b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.

Rationale: The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other responses are not useful for palpation.

The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed?

a. Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain.

b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience.

c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths.

d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

Rationale: Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue.

a. Turgor

b. Texture

c. Density

d. Consistency

c. Density

Rationale: Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation.

The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed?

a. Percussing once over each area

b. Quickly lifting the striking finger after each stroke

c. Striking with the fingertip, not the finger pad

d. Using the wrist to make the strikes, not the arm

a. Percussing once over each area

Rationale: For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm.

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:

a. Auscultate over the area with a fetoscope.

b. Use a goniometer to measure the pulsations.

c. Use a Doppler device to check for pulsations over the area.

d. Check for the presence of pulsations with a stethoscope.

c. Use a Doppler device to check for pulsations over the area.

Rationale: Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the:

a. Examiner feel more comfortable and to gain control of the situation.

b. Examiner to build rapport and to increase the patients confidence in him or her.

c. Patient understand his or her disease process and treatment modalities.

d. Patient identify questions about his or her disease and the potential areas of patient education.

b. Examiner to build rapport and to increase the patients confidence in him or her.

Rationale: Sharing information builds rapport and increases the patients confidence in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present.

A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?

a. Auscultate the lungs and heart while the infant is still sleeping.

b. Examine the infants hips, because this procedure is uncomfortable.

c. Begin with the assessment of the eye, and continue with the remainder of the examination in a head-to-toe approach.

d. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.

a. Auscultate the lungs and heart while the infant is still sleeping.

Rationale: When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures that should be performed at the end of the examination.

The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to:

a. Wear protective eye wear at all times.

b. Wear gloves during any and all contact with patients.

c. Wash hands before and after contact with each patient.

d. Clean the stethoscope with an alcohol swab between patients.

c. Wash hands before and after contact with each patient.

Rationale: The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed.

Which of these statements is true regarding the use of Standard Precautions in the health care setting?

a. Standard Precautions apply to all body fluids, including sweat.

b. Use alcohol-based hand rub if hands are visibly dirty.

c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.

d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.

Rationale: Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat regardless of whether they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.

When examining an infant, the nurse should examine which area first?

a. Ear

b. Nose

c. Throat

d. Abdomen

d. Abdomen

Rationale: The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last.

The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? Select all that apply.

a. Warm the hands first before touching the patient.

b. For deep palpation, use one long continuous palpation when assessing the liver.

c. Start with light palpation to detect surface characteristics.

d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps.

e. Identify any tender areas, and palpate them last.

f. Use the palms of the hands to assess temperature of the skin.

a. Warm the hands first before touching the patient.

c. Start with light palpation to detect surface characteristics.

d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps.

e. Identify any tender areas, and palpate them last.

Rationale: The hands should always be warmed before beginning palpation. Intermittent pressure rather than one long continuous palpation is used; any tender areas are identified and palpated last. Fingertips are used to examine skin texture, swelling, pulsation, and the presence of lumps. The dorsa (backs) of the hands are used to assess skin temperature because the skin on the dorsa is thinner than on the palms.

The nurse is performing a general survey. Which action is a component of the general survey?

a. Observing the patients body stature and nutritional status

b. Interpreting the subjective information the patient has reported

c. Measuring the patients temperature, pulse, respirations, and blood pressure

d. Observing specific body systems while performing the physical assessment

a. Observing the patients body stature and nutritional status

Rationale: The general survey is a study of the whole person that includes observing the patients physical appearance, body structure, mobility, and behavior.

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

a. Increase in body weight from his younger years

b. Additional deposits of fat on the thighs and lower legs

c. Presence of kyphosis and flexion in the knees and hips

d. Change in overall body proportion, including a longer trunk and shorter extremities

c. Presence of kyphosis and flexion in the knees and hips

Rationale: Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?

a. Measuring the infants length by using a tape measure

b. Weighing the infant by placing him or her on an electronic standing scale

c. Measuring the chest circumference at the nipple line with a tape measure

d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones

c. Measuring the chest circumference at the nipple line with a tape measure

Rationale: To measure the chest circumference, the tape is encircled around the chest at the nipple line. The length should be measured on a horizontal measuring board. Weight should be measured on a platform-type balance scale. Head circumference is measured with the tape around the head, aligned at the eyebrows, and at the prominent frontal and occipital bonesthe widest span is correct.

The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:

a. Rapid measurement is useful for uncooperative younger children.

b. Using the TMT is the most accurate method for measuring body temperature in newborn infants.

c. Measuring temperature using the TMT is inexpensive.

d. Studies strongly support the use of the TMT in children under the age 6 years.

a. Rapid measurement is useful for uncooperative younger children.

Rationale: The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use a TMT with newborn infants and young children is conflicting.

When measuring a patients body temperature, the nurse keeps in mind that body temperature is influenced by:

a. Constipation.

b. Patients emotional state.

c. Diurnal cycle.

d. Nocturnal cycle.

c. Diurnal cycle.

Rationale: Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature.

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

a. Wait 30 minutes if the patient has ingested hot or iced liquids.

b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.

c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips.

d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature.

b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.

Rationale: The thermometer should be left in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked.

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this childs respirations?

a. Respirations should be counted for 1 full minute, noticing rate and rhythm.

b. Child's pulse and respirations should be simultaneously checked for 30 seconds.

c. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.

d. Patients respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.

a. Respirations should be counted for 1 full minute, noticing rate and rhythm.

Rationale: Respirations are counted for 1 full minute if an abnormality is suspected. The other responses are not correct actions.

A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is:

a. The numbers are within the normal range and are nothing to worry about.

b. The bottom number is the diastolic pressure and reflects the stroke volume of the heart.

c. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.

d. The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure.

c. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patients question and use terms he can understand.

The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:

a. More clearly hear the Korotkoff sounds.

b. Detect the presence of an auscultatory gap.

c. Avoid missing a falsely elevated blood pressure.

d. More readily identify phase IV of the Korotkoff sounds.

b. Detect the presence of an auscultatory gap.

Rationale: Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when the Korotkoff sounds disappear during auscultation.

The nurse has collected the following information on a patient: palpated blood pressure 180 mm Hg; auscultated blood pressure 170/100 mm Hg; apical pulse 60 beats per minute; radial pulse 70 beats per minute. What is the patients pulse pressure?

a. 10

b. 70

c. 80

d. 100

b. 70

Rationale: Pulse pressure is the difference between systolic and diastolic blood pressure (170-100 = 70) and reflects the stroke volume.

While measuring a patients blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply.

a. The person supports his or her own arm during the blood pressure reading.

b. The blood pressure cuff is too narrow for the extremity.

c. The arm is held above level of the heart.

d. The cuff is loosely wrapped around the arm.

e. The person is sitting with his or her legs crossed.

f. The nurse does not inflate the cuff high enough.

a. The person supports his or her own arm during the blood pressure reading.

b. The blood pressure cuff is too narrow for the extremity.

d. The cuff is loosely wrapped around the arm.

e. The person is sitting with his or her legs crossed.

Rationale: Several factors can result in blood pressure readings that are too high or too low. Having the patients arm held above the level of the heart is one part of the correct technique. (Refer to Table 9-5, Common Errors in Blood Pressure Measurement.)

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.

a. Intact skin appears red but is not broken.

b. Partial thickness skin erosion is observed with a loss of epidermis or dermis.

c. Ulcer extends into the subcutaneous tissue.

d. Localized redness in light skin will blanch with fingertip pressure.

e. Open blister areas have a red-pink wound bed.

f. Patches of eschar cover parts of the wound.

b. Partial thickness skin erosion is observed with a loss of epidermis or dermis.

e. Open blister areas have a red-pink wound bed.

Rationale: Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.

The nurse is preparing for a certification course in 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.

a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color

b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus)

c. Papule: Hypertrophic scar

d. Vesicle: Known as a friction blister

e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color

d. Vesicle: Known as a friction blister

e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

Rationale: A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?

a. Acne

b. Basal cell carcinoma

c. Melanoma

d. Squamous cell carcinoma

b. Basal cell carcinoma

Rationale: Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)

A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is:

a. Just above the diaphragm.

b. Just lateral to the knee cap.

c. At the level of the C7 vertebra.

d. At the level of the T11 vertebra.

c. At the level of the C7 vertebra.

Rationale: The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?

a. III

b. V

c. VII

d. VIII

c. VII

Rationale: Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy).

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:

a. Bell palsy.

b. Damage to the trigeminal nerve.

c. Frostbite with resultant paresthesia to the cheeks.

d. Scleroderma.

b. Damage to the trigeminal nerve.

Rationale: Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________.

a. XI; palpating the anterior and posterior triangles

b. XI; asking the patient to shrug her shoulders against resistance

c. XII; percussing the sternomastoid and submandibular neck muscles

d. XII; assessing for a positive Romberg sign

b. XI; asking the patient to shrug her shoulders against resistance

Rationale: The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:

a. Sternomastoid and trapezius.

b. Spinal accessory and omohyoid.

c. Trapezius and sternomandibular.

d. Sternomandibular and spinal accessory.

a. Sternomastoid and trapezius.

Rationale: The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):

a. Is tender.

b. Is mobile and not hard.

c. Disappears when the patient smiles.

d. Is hard and fixed to the surrounding structures.

b. Is mobile and not hard.

Rationale: Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

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. Diets low in protein and high in carbohydrates may cause enhanced facial bones.

b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer.

c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.

d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.

Rationale: The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect:

a. Hypertension.

b. Cluster headaches.

c. Tension headaches.

d. Migraine headaches.

b. Cluster headaches.

Rationale: Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last to 2 hours each.

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:

a. Exophthalmos.

b. Bowed long bones.

c. Coarse facial features.

d. Acorn-shaped cranium.

c. Coarse facial features.

Rationale: Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease.

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patients trachea is:

a. Pulled to the affected side.

b. Pushed to the unaffected side.

c. Pulled downward.

d. Pulled downward in a rhythmic pattern.

b. Pushed to the unaffected side.

Rationale: The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patients thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient:

a. Has an iodine deficiency.

b. Is exhibiting early signs of goiter.

c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.

d. Needs further testing for possible thyroid cancer.

c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.

Rationale: The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

During an examination, the nurse finds that a patients left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?

a. Crepitation

b. Mastoiditis

c. Temporal arteritis

d. Bell palsy

c. Temporal arteritis

Rationale: With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses.

The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply.

a. Head circumference equal to chest circumference

b. Head circumference greater than chest circumference

c. Head circumference less than chest circumference

d. Fontanels firm and slightly concave

e. Absent tonic neck reflex

f. Nonpalpable cervical lymph nodes

b. Head circumference greater than chest circumference

d. Fontanels firm and slightly concave

f. Nonpalpable cervical lymph nodes

Rationale: An infants head circumference is larger than the chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed the head circumference by 5 to 7 cm. The fontanels should feel firm and slightly concave in the infant, and they should close by age 9 months. The tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally nonpalpable in an infant.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

a. Decreased in the older adult.

b. Impaired in a patient with cataracts.

c. Stimulated by cranial nerves (CNs) I and II.

d. Stimulated by CNs III, IV, and VI.

d. Stimulated by CNs III, IV, and VI.

Rationale: Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI.

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 outer layer of the eye is darkly pigmented to prevent light from reflecting internally.

c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated.

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.

Rationale: The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

a. Thickness or bulging of the lens

b. Posterior chamber as it accommodates increased fluid

c. Contraction of the ciliary body in response to the aqueous within the eye

d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

Rationale: Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

a. The right side of the brain interprets the vision for the right eye.

b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

c. Light rays are refracted through the transparent media of the eye before striking the pupil.

d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

Rationale: The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

The nurse is testing a patients visual accommodation, which refers to which action?

a. Pupillary constriction when looking at a near object

b. Pupillary dilation when looking at a far object

c. Changes in peripheral vision in response to light

d. Involuntary blinking in the presence of bright light

a. Pupillary constriction when looking at a near object

Rationale: The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

a. Increased night vision

b. Dark retinal background

c. Increased photosensitivity

d. Narrowed palpebral fissures

b. Dark retinal background

Rationale: An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

a. Perform the confrontation test.

b. Ask the patient to read the print on a handheld Jaeger card.

c. Use the Snellen chart positioned 20 feet away from the patient.

d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.

c. Use the Snellen chart positioned 20 feet away from the patient.

Rationale: The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

a. At 30 feet the patient can read the entire chart.

b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.

c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.

d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.

Rationale: The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

a. Has poor vision.

b. Has acute vision.

c. Has normal vision.

d. Is presbyopic.

a. Has poor vision.

Rationale: Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.

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 confrontation test.

b. Assess the individuals near vision.

c. Observe the distance between the palpebral fissures.

d. Perform the corneal light test, and look for symmetry of the light reflex.

c. Observe the distance between the palpebral fissures.

Rationale: Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

When assessing the pupillary light reflex, the nurse should use which technique?

a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.

b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction.

c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

d. 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 light across the pupil from the side, and observe for direct and consensual pupillary constriction.

Rationale: To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

The nurse is assessing a patients eyes for the accommodation response and would expect to see which normal finding?

a. Dilation of the pupils

b. Consensual light reflex

c. Conjugate movement of the eyes

d. Convergence of the axes of the eyes

d. Convergence of the axes of the eyes

Rationale: The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

When a light is directed across the iris of a patients eye from the temporal side, the nurse is assessing for:

a. Drainage from dacryocystitis.

b. Presence of conjunctivitis over the iris.

c. Presence of shadows, which may indicate glaucoma.

d. Scattered light reflex, which may be indicative of cataracts.

c. Presence of shadows, which may indicate glaucoma.

Rationale: The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts.

In a patient who has anisocoria, the nurse would expect to observe:

a. Dilated pupils.

b. Excessive tearing.

c. Pupils of unequal size.

d. Uneven curvature of the lens.

c. Pupils of unequal size.

Rationale: Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

a. Loss of central vision.

b. Shadow or diminished vision in one quadrant or one half of the visual field.

c. Loss of peripheral vision.

d. Sudden loss of pupillary constriction and accommodation.

b. Shadow or diminished vision in one quadrant or one half of the visual field.

Rationale: With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have:

a. Macular degeneration.

b. Vision that is normal for someone her age.

c. The beginning stages of cataract formation.

d. Increased intraocular pressure or glaucoma.

a. Macular degeneration.

Rationale: Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?

a. Smooth and clear corneas

b. Opacity of the lens behind the cornea

c. Bleeding from the areas across the cornea

d. Shattered look to the light rays reflecting off the cornea

d. Shattered look to the light rays reflecting off the cornea

Rationale: A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:

a. Hypopyon.

b. Hyphema.

c. Corneal abrasion.

d. Pterygium.

b. Hyphema.

Rationale: Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. (See Table 14-7 for descriptions of the other terms.)

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply.

a. Patient may experience sensitivity to light, nausea, and halos around lights.

b. Patient experiences tunnel vision in the late stages.

c. Immediate treatment is needed.

d. Vision loss begins with peripheral vision.

e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.

f. Virtually no symptoms are exhibited.

b. Patient experiences tunnel vision in the late stages.

d. Vision loss begins with peripheral vision.

f. Virtually no symptoms are exhibited.

Rationale: Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying I'm just getting old! After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply.

a. Occasionally forgetting names or appointments

b. Difficulty performing familiar tasks, such as placing a telephone call

c. Misplacing items, such as putting dish soap in the refrigerator

d. Sometimes having trouble finding the right word

e. Rapid mood swings, from calm to tears, for no apparent reason

f. Getting lost in ones own neighborhood

b. Difficulty performing familiar tasks, such as placing a telephone call

c. Misplacing items, such as putting dish soap in the refrigerator

e. Rapid mood swings, from calm to tears, for no apparent reason

f. Getting lost in ones own neighborhood

Rationale: Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in ones own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. (For other examples of Alzheimer disease, see Table 23-2.)