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Questions and Answers
During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds onto the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:
During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds onto the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:
During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates:
During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates:
The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique?
The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique?
The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct?
The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct?
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The nurse is performing an otoscopic examination on an adult. Which of the following is true?
The nurse is performing an otoscopic examination on an adult. Which of the following is true?
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In performing a voice test to assess hearing, which of the following would the nurse do?
In performing a voice test to assess hearing, which of the following would the nurse do?
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Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti?
Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti?
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A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
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A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:
A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:
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During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:
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A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:
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A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:
A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:
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When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:
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The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:
The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:
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The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?
The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?
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When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?
When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?
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Which of these statements is true regarding the arterial system?
Which of these statements is true regarding the arterial system?
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A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
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The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?
The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?
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A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing:
A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing:
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During an assessment, the nurse uses the "profile sign" to detect:
During an assessment, the nurse uses the "profile sign" to detect:
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The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next?
The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next?
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The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse.
The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse.
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The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
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A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?
A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?
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When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulses:
When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulses:
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During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be:
During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be:
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During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings?
During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings?
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The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+". The nurse recognizes that this reading indicates what type of pulse?
The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+". The nurse recognizes that this reading indicates what type of pulse?
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The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
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Mr. Worrigan is a 67-year-old patient who comes with his son to the ambulatory health centre. On examination of Mr. Worrigan, you note a pulsus alternans. This is associated with:
Mr. Worrigan is a 67-year-old patient who comes with his son to the ambulatory health centre. On examination of Mr. Worrigan, you note a pulsus alternans. This is associated with:
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The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the lobe.
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the lobe.
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A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?
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During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as:
During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as:
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During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?
During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?
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The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient
The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient
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When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
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The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?
The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?
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The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, What would the nurse suspect?
The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, What would the nurse suspect?
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A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
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The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?
The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?
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During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct?
During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct?
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The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?
The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?
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The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patients toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as
The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patients toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as
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The nurse is assessing a patient for carpal tunnel syndrome. Which test is appropriate for this condition?
The nurse is assessing a patient for carpal tunnel syndrome. Which test is appropriate for this condition?
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Study Notes
Objective Vertigo
- A patient experiencing dizziness described as "the room spinning"
Tinnitus
- A patient experiencing a buzzing sound described as "driving me crazy"
Breast Self-Examination (BSE) Technique
- Best time to perform BSE is 4-7 days after the first day of menstruation
- Monthly BSE allows for familiarity with breasts and their normal variations
Otoscopic Examination
- Pull pinna up and back before inserting speculum
Voice Test for Hearing
- Nurse whispers two-syllable words and asks patient to repeat
- Nurse stands about 4 feet away
Cranial Nerve VIII
- Responsible for nerve impulses to the brain from the organ of Corti
Snellen Chart
- If patient cannot read largest letters, shorten distance between patient and chart until letters are seen
Hordeolum (Stye)
- Painful, red, swollen pustule at the lid margin
Extraocular Muscles
- Movement of extraocular muscles is important to monitor during ocular examinations
Visual Acuity
- 20/30 visual acuity means patient can read at 20 feet what a person with normal vision can read at 30 feet
- 20/80 indicates poor vision
Corneal Light Reflex
- Reflection at 2 o'clock in each eye is a normal finding
Periorbital Edema in 70-Year-Old
- Ask patient about history of heart failure
Aortic Aneurysm
- Pulsating mass is usually present
Left Upper Quadrant Tenderness
- Structures in left upper quadrant of abdomen may be involved
Arterial System
- High-pressure system
Venous Disease Risk Factors
- Bed rest for prolonged periods increases risk
Claudication
- Calf pain during exertion relieved by rest, suggests claudication
Arterial Insufficiency
- Patient complains of leg pain, especially at night, when legs are elevated
- Delayed venous filling is a sign
Early Clubbing
- Important finding during a physical assessment
Capillary Refill Time
- A normal capillary refill time is 5 seconds
- If delayed, further investigation is needed
Bounding Pulse
- A bounding pulse is expected in patients with untreated hyperthyroidism
Modified Allen Test
- Evaluates collateral circulation before cannulating the radial artery
Venous Stasis
- Brownish discoloration of lower leg skin is a possible finding
Paradoxical Pulse
- Pulse amplitude weaker during inspiration and stronger during expiration
- Blood pressure decreases during inspiration and increases during expiration
Venous Filling
- Venous filling within 15 seconds is a normal finding
Varicose Veins
- Dilated, tortuous veins in lower legs
Elevated Jugular Venous Pulsations
- Indicates elevated pressure related to heart failure
Pulsus Alternans
- Associated with heart failure
Personality and Cognitive Changes
- Changes in personality and cognitive abilities in an elderly patient may be a concern
Frontal Lobe Function
- Associated with behaviors such as anger, crying easily
Cerebellum Dysfunction
- Problems with balance and rapid alternating movements
Peripheral Neuropathy
- Inability to feel vibrations in certain areas, in a patient with diabetes
Spastic Hemiparesis
- Stiff and extended left leg with circumduction during walking
Cerebrum Function
- Orientation to surroundings involves cerebrum function
Nystagmus
- Severe nystagmus may indicate cerebellar or brainstem disease
Glasgow Coma Scale
- A number indicating the level of consciousness in a coma. Six is the lowest and associated with a coma
Babinski Sign
- Abnormal plantar response in adults with a brain tumor (toes fan out and big toe dorsiflexes)
Carpal Tunnel Syndrome
- A Phalen test or Tinel sign can assist in diagnosis
Crepitation
- A grinding or grating sound, associated with joint conditions
Epicondylitis (Tennis Elbow)
- Tenderness at medial and lateral epicondyles
Musculoskeletal Assessment
- Proximal-to-distal approach
Chronic Disease Risk
- Risk for infection and lesions is higher in patients with chronic conditions
Heart Failure
- Edema in lower legs, may be a symptom
Ascites
- Positive fluid wave during abdominal assessment
Parietal Lobe Dysfunction
- Inability to feel temperature
Cushing Syndrome
- Excessive adrenocorticotropic hormone secretion is a possible diagnosis
- Associated with conditions such as high cortisol levels
McBurney Point
- Located in right lower quadrant, associated with appendicitis
Arterial Ischemic Ulcer
- Pale ischemic ulcer on the great toe is an example
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Description
Test your knowledge on various nursing assessment techniques, including vertigo, tinnitus, and breast self-examination. This quiz covers practical approaches to patient evaluations and important physiological concepts like cranial nerve functions and visual acuity testing. Perfect for nursing students and professionals seeking to refresh their skills.
