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A nurse is assessing a patient's eyes for accommodation. Place the steps of this assessment in the order they are performed.
- A. Document the results in the electronic health record.
- B. Ask the patient to look at a distant object, then back to the object held.
- C. Hold a straight object 10 to 15 cm (4 to 6 inches) from the bridge of the patient's nose.
- D. Observe for pupillary constriction when looking at the near object and for pupillary dilation when looking at the distant object.
- E. Ask the patient to look at the object.
Correct Answer: C,E,B,D,A
Rationale: To test accommodation the nurse holds the forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 inches) from the bridge of the patient's nose. The patient is asked to look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object. The patient must be cooperative to complete this assessment. The results are documented last.
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A nursing student is learning to perform physical assessments. When will the student use the technique of palpation? Select all that apply.
- A. Assessing temperature of a patient's feet
- B. Counting the apical pulse
- C. Assessing for skin turgor
- D. Evaluating lymph nodes
- E. Assessing for dullness over a tumor
- F. Finding a heart murmur
Correct Answer: A,C,D
Rationale: During palpation, the nurse uses the sense of touch to compare bilateral pulses for symmetrical temperature, assess skin turgor, and check for enlarged lymph nodes. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds provide information about the location, shape, size, and density of tissues, such as dullness over a mass or fluid accumulation. Auscultation refers to listening with a stethoscope to sounds produced in the body; counting the apical pulse or auscultating heart sounds/murmurs are examples.
A nurse in the neurology clinic is assessing a patient's eyes for extraocular movements. Which correctly describes the procedure for this test?
- A. Ask the patient to sit about 3 ft away, facing the nurse.
- B. Have the patient follow a penlight held 1 ft from their face slowly through the cardinal positions.
- C. Move a penlight in concentric circular motion in front of the patient's eyes.
- D. Ask the patient to cover one eye with a hand or index card.
Correct Answer: B
Rationale: The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 ft away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal positions of gaze-up and down, left and right, diagonally up and down to the left, diagonally up and down to the right. Option B most accurately describes this procedure.
A nurse is caring for a patient with exacerbation of COPD and pneumonia. When auscultating the lungs, coarse expiratory, low-pitched, and continuous sounds that clear with coughing are present. How will the nurse document this breath sound in the electronic health record?
- A. Rhonchi
- B. Bronchovesicular breath sounds
- C. Stridor
- D. Bronchial breath sounds
Correct Answer: A
Rationale: Rhonchi are abnormal low-pitched, continuous breath sounds auscultated during inspiration and occasionally expiration, indicating that air is passing through or around secretions. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Stridor is a harsh, loud, high-pitched sound auscultated on inspiration indicating narrowing of the upper airway or presence of a foreign body. Bronchial sounds are normal blowing, hollow sounds, auscultated over the larynx and trachea.
The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing assessments can the nurse perform with the patient in this position? Select all that apply.
- A. Assessing the abdomen
- B. Taking peripheral pulses
- C. Performing a breast examination
- D. Auscultating the heart
- E. Assessing vital signs
- F. Assessing balance and gait
Correct Answer: B,C,D
Rationale: In the dorsal recumbent position, the patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles. Vital sign assessment should be done in the sitting position, and evaluating balance and gait is done with the patient in the standing position.
During physical assessment, a nurse inspects a patient's abdomen. What assessment technique does the nurse perform next?
- A. Percussion
- B. Palpation
- C. Auscultation
- D. Whichever provides patient comfort
Correct Answer: C
Rationale: When assessing the abdomen, the sequence for assessment is: inspection, auscultation, percussion, and palpation. Auscultation follows inspection to avoid stimulating bowel sounds during percussion.