Nokea
A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?
- A. Asking the client to stick out his or her tongue and watching for tremors
- B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
- C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
- D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands
Correct Answer: D
Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.
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An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?
- A. The client has a low cardiac output.
- B. The client has a high cardiac output.
- C. The client has a normal cardiac output.
- D. The client will need a blood transfusion.
Correct Answer: C
Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.
During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?
- A. Documents the normal finding
- B. Checks for penile discharge, as this indicates infection
- C. Palpates for a mass in the scrotum, as wrinkling suggests the presence of one
- D. Obtains additional subjective data from the client, focusing on the scrotal abnormality
Correct Answer: A
Rationale: The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.
When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?
- A. Palpating the carotid artery in the upper third of the neck
- B. Palpating both arteries simultaneously to compare amplitude
- C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits
- D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery
Correct Answer: C
Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.
While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?
- A. Pyrosis
- B. Anorexia
- C. Eructation
- D. Dysphagia
Correct Answer: D
Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.
A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse uses which technique?
- A. Tests the right eye, then tests the left eye, and finally tests both eyes together
- B. Assesses both eyes together, then assesses the right and left eyes separately
- C. Asks the client to stand 40 feet from the chart and read the largest line on the chart
- D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision
Correct Answer: A
Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot at the client's eye level, with the client positioned exactly 20 feet from the chart. The client shields one eye at a time with an opaque card during the test. After testing each eye separately, both eyes are assessed together. The client is asked to read the smallest line of letters visible and encouraged to read the next smallest line as well. Therefore, option A is correct as it describes the correct technique of testing one eye at a time before assessing both eyes together. Option B is incorrect as it assesses both eyes together first, which is not the standard procedure. Options C and D are incorrect as they suggest standing 40 feet from the chart, which contradicts the standard distance of 20 feet for a Snellen chart test.