NUR 325 HEALTH ASSESSMENT EXAM 2 STUDY GUIDE
While examining the patient's neck, the nurse finds the trachea midline but has difficulty
palpating the thyroid. What action would the nurse take next? - Answers :Document this
finding as normal.
The lymph nodes that lie superficial to the mastoid bone are the: - Answers :Posterior
auricular nodes.
Which of the following descriptions is most consistent with a patient who has
hypothyroidism? - Answers :Slightly obese female with periorbital edema and a flat
facial expression, who complains of constipation, decreased appetite, and fatigue.
Physical examination of a patient reveals an enlarged tonsilar node. Acutely infected
nodes would be.. - Answers :Firm but movable and tender.
Which of the following symptoms would the nurse expect the patient to report as
translucent specks that drift across the visual field? - Answers :Floater
When working with an older adult, what would the nurse emphasize as increased risks
for the patient? - Answers :Glaucoma and cataracts
A school nurse is performing annual vision screening for seventh grade students. Which
of the following charts would the nurse most likely be using? - Answers :Snellen's chart
Which of the following scores for distance vision indicates the patient with the poorest
vision? - Answers :20/100
The nurse recognizes that the 60-yr-old patient may have difficulty reading fine print
because of the loss in the ability of the eye to - Answers :accommodate
Peripheral vision is evaluated by the nurse using - Answers :confrontation test
The cranial nerves involved with eye movement include - Answers :III, IV, and VI
The nurse assesses the response of the eye to light and documents normal findings -
Answers :PERRLA
The function of the ear is for - Answers :hearing and equilibrium
The inner ear - Answers :provides the body with proprioception
Cues of hearing loss include which of the following - Answers :All answers are correct
which include
A. Using a loud or monotonous voice
B. Asking to repeat questions
,C. Concentrating on lip movement
D, Leaning forward to hear
Risk factors for hearing loss include which of the following? - Answers :Frequent ear
infections
Exposure to smoke
Tinnitus is described as - Answers :ringing in the ear
Which of the following patients is most likely to have hearing loss? - Answers
:Caucasian man older than 70 years.
Which of the following differentiates the RN assessment from the APRN assessment? -
Answers :Otoscopic assessment
A nursing diagnosis appropriate for a patient with ear problems includes - Answers
:disturbed sensory perception
An outcome that is appropriate for a patient with hearing impairment is - Answers
:Patient explains plan to accommodate hearing impairment.
Which of the following are appropriate interventions for the patient who is at risk for ear
infection? - Answers :Be current on immunizations
Avoid second hand smoke
Clean only external ear
Which of the following is part of the upper gastrointestinal tract? - Answers :Throat
The nurse is assessing the nares to evaluate the site of epistaxis. The most common
site of bleeding is which of the following? - Answers :Kesselbach plexus
The know that the floor of the mouth is highly vascular so it is a good location for which
of the following? - Answers :Absorption of sublingual medications
Acute airway obstruction is a situation that should be - Answers :quickly assessed and
treated.
Risk factors for nose, sinus, mouth, and throat problems include - Answers :topical
decongestant use, smoking, and allergies
The nurse has assessed the nose and documents normal findings as - Answers :nose
symmetrical and midline
The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral
assessment is important because of the increased risk for which of the following? -
Answers :C. albicans
, An adolescent male presents with complaints of nosebleeds. The nurse would further
asses for - Answers :nasal trauma
The nurse assesses the child with purulent unilateral nasal discharge. The nurse know
that the most like causative factor is - Answers :foreign body in nose
The nurse can best evaluate the strength of the sternocleidomastoid muscle by having
the patient... - Answers :turn his or her head against resistance
Which of the following best describes the instructions the nurse should give a patient
when assessing the thyroid from the posterior approach? - Answers :Please look
straight ahead and tilt your head slightly down and to the right side.
While assessing a patient, the nurse finds a palpable lymph node in the left
supraclavicular region. Which of the following should be the next action? - Answers
:Recognize that a palpable node in this region is a dangerous indication of metastatic
cancer that requires further evaluation.
While reviewing laboratory values for thyroid function on an adult patient, the nurse
sees that the TSH is elevated, and the T3 and T4 are decreased/ The nurse recognizes
that these findings are indicative of - Answers :hypothyroidism
A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one
side. This finding is most likely associated with pathology of which cranial nerve? -
Answers :Cranial nerve VII
Which of the following patients would require the most emergent nursing care? -
Answers :A 20-yr-old man with sudden visual loss after playing football.
Which of the following teaching points would the nurse emphasize related to eye
health? - Answers :Always wear eye protection for occupational exposures.
During routine physical examination of a 20-yr-old woman, the nurse notes a septal
perforation. This finding may be significant for which of the following causes? - Answers
:Illicit drug use
refers to drooping of an upper eyelid of one or both eyes. The droop may be barely
noticeable, or the lid can descend over the entire pupil. Can affect both children and
adults, but usually occurs because of aging. - Answers :Ptosis
Epidermis - Answers :Is thin but tough. Its cells are bound tightly together into sheets
that form a rugged protective barrier. It is stratified into several zones. The inner basal
cell layer forms new skin cells. Their major ingredient is the tough, fibrous protein
keratin. The melanocytes interspersed along this layer produce the pigment melanin,
which gives brown tones to the skin and hair. People of all skin colors have the same
While examining the patient's neck, the nurse finds the trachea midline but has difficulty
palpating the thyroid. What action would the nurse take next? - Answers :Document this
finding as normal.
The lymph nodes that lie superficial to the mastoid bone are the: - Answers :Posterior
auricular nodes.
Which of the following descriptions is most consistent with a patient who has
hypothyroidism? - Answers :Slightly obese female with periorbital edema and a flat
facial expression, who complains of constipation, decreased appetite, and fatigue.
Physical examination of a patient reveals an enlarged tonsilar node. Acutely infected
nodes would be.. - Answers :Firm but movable and tender.
Which of the following symptoms would the nurse expect the patient to report as
translucent specks that drift across the visual field? - Answers :Floater
When working with an older adult, what would the nurse emphasize as increased risks
for the patient? - Answers :Glaucoma and cataracts
A school nurse is performing annual vision screening for seventh grade students. Which
of the following charts would the nurse most likely be using? - Answers :Snellen's chart
Which of the following scores for distance vision indicates the patient with the poorest
vision? - Answers :20/100
The nurse recognizes that the 60-yr-old patient may have difficulty reading fine print
because of the loss in the ability of the eye to - Answers :accommodate
Peripheral vision is evaluated by the nurse using - Answers :confrontation test
The cranial nerves involved with eye movement include - Answers :III, IV, and VI
The nurse assesses the response of the eye to light and documents normal findings -
Answers :PERRLA
The function of the ear is for - Answers :hearing and equilibrium
The inner ear - Answers :provides the body with proprioception
Cues of hearing loss include which of the following - Answers :All answers are correct
which include
A. Using a loud or monotonous voice
B. Asking to repeat questions
,C. Concentrating on lip movement
D, Leaning forward to hear
Risk factors for hearing loss include which of the following? - Answers :Frequent ear
infections
Exposure to smoke
Tinnitus is described as - Answers :ringing in the ear
Which of the following patients is most likely to have hearing loss? - Answers
:Caucasian man older than 70 years.
Which of the following differentiates the RN assessment from the APRN assessment? -
Answers :Otoscopic assessment
A nursing diagnosis appropriate for a patient with ear problems includes - Answers
:disturbed sensory perception
An outcome that is appropriate for a patient with hearing impairment is - Answers
:Patient explains plan to accommodate hearing impairment.
Which of the following are appropriate interventions for the patient who is at risk for ear
infection? - Answers :Be current on immunizations
Avoid second hand smoke
Clean only external ear
Which of the following is part of the upper gastrointestinal tract? - Answers :Throat
The nurse is assessing the nares to evaluate the site of epistaxis. The most common
site of bleeding is which of the following? - Answers :Kesselbach plexus
The know that the floor of the mouth is highly vascular so it is a good location for which
of the following? - Answers :Absorption of sublingual medications
Acute airway obstruction is a situation that should be - Answers :quickly assessed and
treated.
Risk factors for nose, sinus, mouth, and throat problems include - Answers :topical
decongestant use, smoking, and allergies
The nurse has assessed the nose and documents normal findings as - Answers :nose
symmetrical and midline
The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral
assessment is important because of the increased risk for which of the following? -
Answers :C. albicans
, An adolescent male presents with complaints of nosebleeds. The nurse would further
asses for - Answers :nasal trauma
The nurse assesses the child with purulent unilateral nasal discharge. The nurse know
that the most like causative factor is - Answers :foreign body in nose
The nurse can best evaluate the strength of the sternocleidomastoid muscle by having
the patient... - Answers :turn his or her head against resistance
Which of the following best describes the instructions the nurse should give a patient
when assessing the thyroid from the posterior approach? - Answers :Please look
straight ahead and tilt your head slightly down and to the right side.
While assessing a patient, the nurse finds a palpable lymph node in the left
supraclavicular region. Which of the following should be the next action? - Answers
:Recognize that a palpable node in this region is a dangerous indication of metastatic
cancer that requires further evaluation.
While reviewing laboratory values for thyroid function on an adult patient, the nurse
sees that the TSH is elevated, and the T3 and T4 are decreased/ The nurse recognizes
that these findings are indicative of - Answers :hypothyroidism
A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one
side. This finding is most likely associated with pathology of which cranial nerve? -
Answers :Cranial nerve VII
Which of the following patients would require the most emergent nursing care? -
Answers :A 20-yr-old man with sudden visual loss after playing football.
Which of the following teaching points would the nurse emphasize related to eye
health? - Answers :Always wear eye protection for occupational exposures.
During routine physical examination of a 20-yr-old woman, the nurse notes a septal
perforation. This finding may be significant for which of the following causes? - Answers
:Illicit drug use
refers to drooping of an upper eyelid of one or both eyes. The droop may be barely
noticeable, or the lid can descend over the entire pupil. Can affect both children and
adults, but usually occurs because of aging. - Answers :Ptosis
Epidermis - Answers :Is thin but tough. Its cells are bound tightly together into sheets
that form a rugged protective barrier. It is stratified into several zones. The inner basal
cell layer forms new skin cells. Their major ingredient is the tough, fibrous protein
keratin. The melanocytes interspersed along this layer produce the pigment melanin,
which gives brown tones to the skin and hair. People of all skin colors have the same
