A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve 1 is intact?
A. The client can stick their tongue out
B. The client can smile symmetrically
C. The client can hear whispered words
D. The client can identify a minty scent ...
NUR 216 Exam 3 (All Accurately Answered)
A nurse is assessing a client's cranial nerves. Which of the following client actions is an
indication that cranial nerve 1 is intact?
A. The client can stick their tongue out
B. The client can smile symmetrically
C. The client can hear whispered words
D. The client can identify a minty scent correct answers D. The client can identify a minty scent
Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test this nerve's
function, the nurse should ask the client to identify a nonirritating aroma, such as mint or coffee
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping
sound upon inspiration of the clients breathing. The nurse should identify this observation as
which of the following findings?
A. Crackles
B. Stridor
C. Wheezes
D. Friction Rub correct answers A. Crackles
Rationale- crackles, sometimes called rales, are wet, popping sounds created by air moving
through liquid or by collapsed alveoli snapping open on inspiration. They are most common at
the end of inspiration of breathing.
A nurse is performing a cardiovascular assessment on a client which of the following findings
should the nurse expect?
A. A continuous sensation of vibration felt over the second and third left intercostal spaces
B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum
C. A brief thump felt near the fourth or fifth intercostal space near the left mid clavicular line
D. A whooshing or swishing sound over the second intercostal space along the left arsenal border
correct answers C. A brief thump felt near the fourth or fifth intercostal space near the left mid
clavicular line
Rationale- This is where you would inspect and palpate for the point of maximal impulse. Also
called an apical pulse station, it occurs as the Apex of the heart bumps against the chest wall with
each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is
an expected finding and should be performed when you are preparing to auscultate the apical
pulse.
The nurse is preparing to perform a comprehensive physical assessment on a client. Which of the
following actions should the nurse plan to take first?
A. Document accurate data
B. Develop a plan of care
C. Validate previous data
D. Evaluate outcomes of care correct answers B. Develop a plan of care
Rationale- The first action the nurse should take using the nursing process is to assess the client
and develop a plan of care. The nursing process follow the steps of assessment, analysis,
planning, implementation, and evaluation.
, A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies pressure over
the area with their fingertips, then quickly releases it. The client reports increased pain on the
release of pressure. Which of the findings should the nurse document?
A. Borborygmi
B. Rebound Tenderness
C. Tympany
D. Abdominal Guarding correct answers B. Rebound Tenderness
Rationale- The nurse should document that the client is experiencing rebound tenderness, which
is an increase in pain when deep palpation over a tender area is released. Rebound tenderness is
in the right lower quadrant at McBurney's point (one-third the distance from the anterior iliac
crest to the umbilicus) is an indication of acute appendicitis.
A nurse is performing a physical examination of the spine for an older adult client. The nurse
should identify that which of the following findings is common with aging?
A. Lordosis
B. Kyphosis
C. Ankylosis
D. Scoliosis correct answers B. Kyphosis
Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal
angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most
common in older adults and tends to increase with aging. This pronounced convexity of the
thoracic spine is also common in older clients who have had vertebral fractures.
Disorders in which parts of the ear usually result in earaches?
A. Inner and middle ear
B. Inner and external ear
C. Middle and external ear
D. Travis and eardrum correct answers B. Inner and external ear
Eye discharge is usually associated with:
A. Hypertension (HTN)
B. Conjunctivitis
C. Otitis externa
D. Meibomianitis correct answers B. Conjunctivitis
Which type of hearing loss results from disorders of the inner ear or of the eighth cranial nerve?
A. Conductive hearing loss
B. Sensorineural hearing loss
C. Mixed hearing loss
D. Functional hearing loss correct answers B. Sensorineural hearing loss
Which term is used to test for corneal sensitivity?
A. Cotton-tipped applicator
B. Gauze pad
C. Tissue
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