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A patient has come to the emergency department with symptoms of a stroke. During the assessment, the nurse asks the patient to raise their eyebrows, smile, and show their teeth to evaluate which cranial nerve?
- A. Olfactory
- B. Optic
- C. Facial
- D. Vagus
Correct Answer: C
Rationale: Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise their eyebrow, smile, and show their teeth. The olfactory nerve (cranial nerve I) is tested by testing the sense of smell using various familiar substances. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.
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A nurse admitting a patient to a long-term care facility performs a functional assessment. Which questions will the nurse include as part of the assessment? Select all that apply.
- A. Are you able to dress yourself?
- B. Do you have a history of smoking?
- C. What is the problem for which you are seeking care?
- D. Do you prepare your own meals?
- E. Do you manage your own finances?
- F. Whom do you rely on for support?
Correct Answer: A,D,E
Rationale: A functional health assessment including strengths and areas needing improvement focuses on the effects of health or illness on a patient's quality of life. Questions about the patient's ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances are included. A history of smoking is a lifestyle factor, and the chief complaint is the reason for seeking health care; both are assessed during the health history. Social networks and support psychosocial factors are also assessed during the health history.
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.
A school nurse assesses adolescents' visual acuity using a Snellen eye chart. Which explanation does the nurse provide to the student whose vision is 20/40 in both eyes?
- A. They see better than 50% of people.
- B. Double vision is present.
- C. Vision is less than normal.
- D. They have normal vision.
Correct Answer: C
Rationale: Normal vision is 20/20. The higher the denominator indicates increasingly worse vision; 20/40 vision indicates less than normal vision.
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.
The nurse is caring for a patient experiencing bronchospasm due to an exacerbation of asthma. During auscultation, the nurse anticipates the presence of which breath sound?
- A. Sibilant
- B. Wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: B
Rationale: Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways, such as with bronchospasm found in asthma or COPD. Rhonchi are low-pitched, continuous sounds with a snoring quality, which may clear with coughing; they occur when air passes through secretions. Crackles are discontinuous bubbling, cracking, or popping, low- to high-pitched sounds, that occur when air passes through fluid in the airways.