Chapter 20 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 20

Question 1

Type: MCSA

When assessing the patients cognitive function, the nurse would evaluate which parameter?

1. Ability to smell items placed under the nose while eyes are closed

2. Orientation to time, place, and person, and ability to recall recent and past events

3. Ability to walk with a smooth, steady gait

4. Level of consciousness

Correct Answer: 2

Rationale 1: This assessment method is used to test for cranial nerve 1, the olfactory nerve.

Rationale 2: Orientation to time, place, and person and ability to recall recent and past events is part of cognitive ability.

Rationale 3: Gait is not reflective of cognitive ability.

Rationale 4: Level of consciousness is not reflective of cognitive ability.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 2

Type: MCSA

When testing cranial nerve XI (spinal accessory), the nurse should ask the patient to perform which activity?

1. Shrug the shoulders and turn the head against resistance.

2. Stick out the tongue and move it from side to side.

3. Taste foods and distinguish sweet from sour.

4. Identify smells correctly with one side of the nares blocked.

Correct Answer: 1

Rationale 1: Cranial nerve XI, the spinal accessory nerve, is tested by asking the patient to shrug the shoulders and turn the head against resistance.

Rationale 2: Cranial nerve XII, the hypoglossal nerve, is tested by asking the patient to stick out the tongue and move it from side to side.

Rationale 3: Cranial nerve VII, the facial nerve, is tested by asking the patient to distinguish between different tastes.

Rationale 4: Cranial nerve I, the olfactory nerve, is tested by having the patient identify smells correctly with one side of the nose blocked.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 3

Type: MCSA

The nurse observes a patient who has a lack of coordination, clumsy movements, and an unbalanced gait. How would the nurse document this observation?

1. As flaccidity

2. As paralysis

3. As hemiparesis

4. As ataxia

Correct Answer: 4

Rationale 1: Flaccidity is an abnormal condition in which movement does not occur at all in a part or is impaired.

Rationale 2: Paralysis is an abnormal condition in which movement does not occur at all in a part.

Rationale 3: Hemiparesis is an abnormal condition in which movement does not occur at all in half of the body.

Rationale 4: In ataxia, there is a lack of coordination, clumsy movements, and an unbalanced gait.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-1

Question 4

Type: MCSA

What precaution must the nurse take when performing the Romberg test?

1. Have the patient remain seated.

2. Stand close to the patient.

3. Have the patient keep the eyes open.

4. Warn the patient that a sharp object is being used for the test.

Correct Answer: 2

Rationale 1: The Romberg test is not done with the patient in a seated position.

Rationale 2: The patient may lose balance during this test. Injury is a possibility, so the nurse should stand close to the patient.

Rationale 3: The Romberg test is done with the eyes closed.

Rationale 4: The Romberg test does not require use of a sharp object.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 5

Type: MCSA

What should the nurse include in the assessment of muscle strength and movement?

1. Grade the posterior tibial pulses.

2. Grade flaccidity.

3. Observe to see whether strength and movement are bilaterally equal and strong.

4. Percuss the muscle for dullness.

Correct Answer: 3

Rationale 1: Pulses relate to blood supply, not muscles.

Rationale 2: It is not possible to grade flaccidity. When muscles are flaccid, there is no movement.

Rationale 3: The nurse should always compare one side to the other when an extremity is being assessed and note whether there is a difference in strength or movement from side to side.

Rationale 4: Assessment of muscle strength and movement does not include percussion.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 6

Type: MCSA

The patient has upper motor neuron injuries. The nurse anticipates that what type of reflex is present?

1. Pathologic

2. Increased

3. Normal

4. Exaggerated

Correct Answer: 1

Rationale 1: Pathologic reflexes such as a positive Babinski reflex are expected with upper motor neuron injuries.

Rationale 2: The reflexes are not graded as increased.

Rationale 3: This patients reflexes would not be considered normal.

Rationale 4: This patients reflexes would not be considered exaggerated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

Question 7

Type: MCMA

Which terms would a nurse use to document abnormal posturing in an adult with a neurological deficit?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Decorticate posturing

2. Decerebrate posturing

3. Circumduction

4. Steppage

5. Nystagmus

Correct Answer: 1,2

Rationale 1: In decorticate posturing, the upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed.

Rationale 2: In decerebrate posturing, the neck is extended; the jaw is clenched; the arms are pronated, extended, and close to the sides; the legs are extended straight out; and the feet are plantar flexed.

Rationale 3: Circumduction refers to a circular movement of a limb.

Rationale 4: Steppage is a gait abnormality.

Rationale 5: Nystagmus is a term for the involuntary eye movements that may be seen in stroke patients.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 8

Type: MCMA

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which action by the nurse is most appropriate for minimizing the patients risk for injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Identify the patients fall risk category.

2. Assess the patients gag reflex prior to offering food or liquids.

3. Assist the patient with bedside sitting or toileting.

4. Assess the patients vision using a Snellen chart.

5. Place a red falls risk bracelet on the patients arm.

Correct Answer: 1,3,5

Rationale 1: Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed balance, putting the patient at risk for falls.

Rationale 2: Dysfunction of the glossopharyngeal (CN IX) and vagus (CN X) nerves is likely to result in a poor or absent gag reflex.

Rationale 3: Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed balance, putting the patient at risk for falls. Precautions to minimize this risk should be implemented.

Rationale 4: A Snellen chart is an eye chart used to measure visual acuity that may be altered due to dysfunction of the optic nerve (CN II).

Rationale 5: Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed balance, putting the patient at risk for falls. Precautions to minimize this risk should be implemented.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-3

Question 9

Type: MCSA

During an assessment of a patients cranial nerves, the nurse asks the patient to stick out the tongue. The nurse observes that the tongue deviates markedly to the right side. Which condition is the patient most likely exhibiting?

1. Abnormal hypoglossal nerve response

2. First cranial nerve (CN I) damage

3. Sluggish oculomotor response

4. Absence of Homans sign

Correct Answer: 1

Rationale 1: Cranial nerve XII (hypoglossal) is tested by having the patient stick his or her tongue out. An abnormal finding is that the tongue deviates to either side.

Rationale 2: Cranial nerve I is the olfactory nerve and is assessed by having the patient use his or her sense of smell.

Rationale 3: Cranial nerve III is the oculomotor nerve and, along with the trochlear and abducens nerves, helps the eye move.

Rationale 4: Homans sign is a check for thrombophlebitis in the calves of the legs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 10

Type: MCSA

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the

most appropriate action by the nurse?

1. Treat the patients pain.

2. Assess the patients airway, breathing, and circulation.

3. Obtain a complete history from the patient.

4. Triage the patient with the other ED patients.

Correct Answer: 2

Rationale 1: Another action is the nurses priority.

Rationale 2: The GCS (Glasgow Coma Scale) is a standardized system for assessing consciousness. A score of 15 indicates full alertness, and a score of 8 or less is usually indicative of coma. A comatose patient receives high priority, and the nurse will utilize the ABCs of care in this case. Additionally, assessment is the first step of the nursing process.

Rationale 3: This patient will not be able to respond to questions.

Rationale 4: The patient should receive priority care in the ED.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-1

Question 11

Type: MCSA

When bringing in the meal tray for a patient with damage to the glossopharyngeal nerve (CN IX), which action by the nurse is most appropriate?

1. Place the tray on the patients right side.

2. Assess the patients ability to swallow.

3. Speak loudly and make eye contact with the patient.

4. Assist the patient in identifying where items are on the tray.

Correct Answer: 2

Rationale 1: The optic nerve (CN II) controls vision. There should be no extinction present in this patient.

Rationale 2: Gag reflex and swallowing are controlled by CN IX.

Rationale 3: Auditory function is controlled by the acoustic nerve (CN VIII).

Rationale 4: The optic nerve (CN II) controls vision.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-3

Question 12

Type: MCSA

The nurse has just finished explaining to a patients son the function of the Mini-Mental Status Examination (MMSE). Which statement by the patients son indicates his understanding?

1. This test will evaluate my dads ability to think, reason, and make decisions.

2. This test will give us a good idea if Dad is mentally healthy enough to live alone.

3. If Dad passes this test, we will know that his mind is still okay.

4. Im sure Dad will do well on the test; hes always been smart.

Correct Answer: 1

Rationale 1: The MMSE assesses the higher cortical functions of thinking and reasoning as well as level of consciousness, orientation, attention, memory, affect and insight, speech and language, fund of knowledge, and abstraction.

Rationale 2: There are other factors besides those evaluated by the MMSE that can impact ones ability to live independently.

Rationale 3: The MMSE evaluation is not a pass/fail type of testing and does not provide definitive proof of mental wellness.

Rationale 4: Intelligence is not the focus of the evaluation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 20-1

Question 13

Type: MCSA

While assessing an unconscious patients neurologic status, the nurse applies pain by pinching the sternocleidomastoid muscle. Which statement by the nurse indicates an understanding of the use of this technique?

1. Pain will make abnormal motor responses observable.

2. An unconscious patients pain threshold is abnormally high.

3. Response to pain is an indicator of cognitive function.

4. The patient is most likely to respond to pain at that site.

Correct Answer: 1

Rationale 1: In the unconscious patient, a painful stimulus such as the sternocleidomastoid pinch may elicit an observable abnormal motor response.

Rationale 2: The pain threshold of an unconscious patient is not necessarily high.

Rationale 3: Cognitive function is not tested by introduction of painful stimuli.

Rationale 4: It is the presence of pain, not its location, that is likely to elicit a response.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-5

Question 14

Type: MCMA

Which techniques would the nurse use to test for graphesthesia?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ask the patient to identify an object placed in the hand.

2. Have the patient close the eyes.

3. Ask the patient to occlude the ear not being tested.

4. Trace a letter in the palm of the patients hand.

5. Lightly touch both sides of the patient simultaneously.

Correct Answer: 2,4

Rationale 1: Asking the patient to identify an object placed in the hand tests for stereognosis.

Rationale 2: This test should be performed with eyes closed.

Rationale 3: The ear is not included in testing for graphesthesia.

Rationale 4: Graphesthesia is the sense by which a person recognizes figures or numbers written on the skin.

Rationale 5: Touching the patient on both sides simultaneously tests the extinction phenomenon.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 15

Type: MCMA

The patient is exhibiting abnormal posturing to stimuli. Which findings would the nurse document as decerebrate posturing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The arms are rigidly extended.

2. The toes are pointed downward.

3. The teeth are clenched.

4. The chin is held against the chest.

5. The arms are hypersupinated.

Correct Answer: 1,2,3

Rationale 1: Rigid extension is characteristic of decerebrate posturing.

Rationale 2: The extension of the feet makes the toes point downward in decerebrate posturing.

Rationale 3: Clenching of the teeth occurs in decerebrate posturing.

Rationale 4: Backward arching of the neck is characteristic of decerebrate posturing.

Rationale 5: In decerebrate posturing, the arms are hyperpronated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

Question 16

Type: MCSA

The nurse reads that a patients reflexes are 3+. How does the nurse interpret this score?

1. The reflexes are weaker than normal.

2. The reflexes are normal.

3. The reflexes are stronger than normal.

4. The reflexes are hyperactive.

Correct Answer: 3

Rationale 1: 1+ reflexes are weaker than normal.

Rationale 2: 2+ reflexes are normal.

Rationale 3: 3+ reflexes are stronger than normal.

Rationale 4: 4+ reflexes are hyperactive, with sustained clonus.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-4

Question 17

Type: FIB

A patient is brought to the emergency department following a motor vehicle accident. The patient jerks away from the nurse attempting to start an IV in the right arm and says, Bring me my book. I need to eat. When asked what happened in the accident, the patient looks frantically from nurse to nurse and says, I have a dog. Calculate the patients Glasgow Coma Scale score.

Standard Text:

Correct Answer: 12

Rationale : The patient scores 4 for spontaneous eye-opening, 5 for localizing pain and having a motor response by pulling away, and a 3 for using inappropriate words. 4 + 5 + 3 = 12.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 18

Type: MCSA

An intensive care unit (ICU) nurse is preparing to assess the level of consciousness (LOC) of a patient who experienced multiple trauma injuries and is on assisted ventilation. The nurse chooses the FOUR Score Consciousness Scale for which reason?

1. This scoring system does not require verbal responses.

2. This scoring system focuses primarily on assessment of cognitive ability.

3. This scoring system requires minimal interaction on the part of the patient.

4. This scoring system is designed especially for intensive care unit patients.

Correct Answer: 1

Rationale 1: Verbal response is not a component of the FOUR Score Consciousness Scale, making it fully applicable to intubated clients.

Rationale 2: Cognitive ability is not assessed by this tool.

Rationale 3: The tool does require patient participation in evaluating its four focus components: eye, motor, brainstem, and respiration.

Rationale 4: The system is not designed for patients in specific hospital units.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 20-1

Question 19

Type: MCSA

The nurse is interviewing a patient whose wife reports, Hes really forgetting things more these days. To provide the best assessment of this complaint, what should the nurse do first?

1. Ask the wife to give examples of the patients forgetfulness.

2. Have the patient take the Mini-Mental Status Examination (MMSE).

3. Use the mnemonic OLD CARTS to obtain assessment data.

4. Ask the patient if he too feels hes forgetful.

Correct Answer: 3

Rationale 1: Asking the wife for examples of the patients alleged forgetfulness is not the best assessment method available.

Rationale 2: The nurse may administer the MMSE, but this is not the first action.

Rationale 3: To obtain as full a description of the reported forgetfulness as possible, the nurse should use the mnemonic OLD CARTS (Onset, Location, and Duration of symptoms, Characteristics, Aggravating/associated factors, Relieving factors, Temporal factors, and Severity of symptoms) to ensure that all necessary information is obtained.

Rationale 4: Patient report will not provide as much information as needed for this assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-2

Question 20

Type: MCSA

The nurse recognizes that which assessment observation of a comatose patient has the greatest implications?

1. Both arms are extended and adducted, with the palms facing down.

2. Fasciculational twitching occurs in the small muscle groups of both arms.

3. Muscles of the entire upper extremities are flaccid bilaterally.

4. Arms, wrist, and fingers are flexed and adducted.

Correct Answer: 1

Rationale 1: This description is characteristic of decerebrate posturing, which indicates severe brain damage.

Rationale 2: Fasciculational twitching is involuntary, arising from the spontaneous discharge of a bundle of skeletal muscle fibers, and is usually benign.

Rationale 3: This description is characteristic of paralysis. The implications of another finding are more serious.

Rationale 4: This description is characteristic of decorticate posturing. The implications of another finding are more serious.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

Question 21

Type: MCSA

The nurse recognizes which observation as a positive Babinski sign?

1. Inability to identify two simultaneous points of pain on the foot

2. Curling of all the toes in response to stroking stimulation

3. Feeling a buzzing sensation in the foot when touched with a tuning fork

4. Dorsiflexion of the great toe, with fanning of the other toes

Correct Answer: 4

Rationale 1: Two-point discrimination is tested by touching the patient with one or two sharp objects at the same time; the inability to identify if there were multiple pain sites reflects pathology.

Rationale 2: Curling of the toes is not a positive Babinski sign.

Rationale 3: Vibratory sense is tested using a tuning fork on one of a variety of bony prominences. A diminished buzzing sensation is pathological.

Rationale 4: Dorsiflexion of the great toe with fanning of the other toes shows pathologic reflexes (positive Babinski sign).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

Question 22

Type: MCSA

When the nurse assesses the patients abdominal superficial reflexes, the umbilicus moves in the direction of the skin stimulated. How would the nurse document this observation?

1. An absence of response

2. A questionable response

3. A negative (-) response

4. A present (+) response

Correct Answer: 4

Rationale 1: Moving in the direction of the skin being stimulated is a response.

Rationale 2: Responses are not documented as questionable.

Rationale 3: Superficial responses are not documented as positive or negative.

Rationale 4: Superficial reflexes are scored as either present (+) or absent (-). The umbilicus moving in the direction of the skin being stimulated is a (+) response.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-5

Question 23

Type: MCSA

The nurse is about to educate a 75-year-old patient on the side effects of a newly prescribed medication. The patient is both hearing and vision impaired. What should be the nurses primary intervention?

1. Be sure that the patient has glasses on and functioning hearing aids during the discussion.

2. Arrange for the patients room to be well lighted and quiet during the teaching session.

3. Provide a written explanation to supplement the discussion.

4. Ask that a family member be present during the teaching session.

Correct Answer: 1

Rationale 1: For the patient to be best prepared to respond to the instructions, the sensory deficiencies must be first addressed; making sure the assistive devices are properly in place and working is the initial intervention.

Rationale 2: The patients room should be well lighted, but this is not the nurses primary intervention.

Rationale 3: Providing written information is important, but it is not the nurses primary intervention.

Rationale 4: It may be important for a family member to be present. This will be determined by the patients condition. This is not the primary nursing intervention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 20-6

Question 24

Type: MCSA

The nurse is preparing to administer a Mini-Mental Status Examination (MMSE) on a 75-year-old patient admitted for clinical depression. What is the nurses primary intervention for this specific patient?

1. Make sure the patient is not hungry or in pain when taking the test.

2. Repeat the instructions just prior to beginning the assessment.

3. Arrange for the patient to be uninterrupted during the test.

4. Plan for the test when the patient will not be rushed to complete it.

Correct Answer: 4

Rationale 1: Addressing hunger and pain issues are interventions that are appropriate for any patient, regardless of age.

Rationale 2: Repeating the instructions is an intervention appropriate for any patient, regardless of age.

Rationale 3: Arranging for uninterrupted teaching time is an intervention appropriate for any patient, regardless of age.

Rationale 4: Planning for the test when the patient will not be rushed to complete it is particularly important because of the elderly patients decreased processing speed. The older patient should be given adequate time to respond to the examination items.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 20-6

Question 25

Type: MCMA

The nurse is using the OLD CARTS mnemonic to assess a patients chief complaint of dizziness. Which information would the nurse interpret as temporal factors?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I have had dizziness off and on for a week.

2. I get dizzy 2 or 3 times a day.

3. My dizziness usually begins when I get out of bed in the morning.

4. The dizziness usually lasts for 20 to 30 seconds.

5. The dizziness comes on suddenly and leaves suddenly.

Correct Answer: 2,3,5

Rationale 1: This information is related to onset of symptoms.

Rationale 2: The frequency of occurrence is recorded under temporal factors.

Rationale 3: The information that the dizziness is associated with an activity is recorded under temporal factors.

Rationale 4: How long the dizziness lasts would be recorded under duration of symptom.

Rationale 5: Rapidity of onset is recorded under temporal factors.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-2

Question 26

Type: FIB

The patients vision is recorded as 20/50. The nurse is measuring what this patient can see as compared to what a normal eye can see at _______ feet.

Standard Text:

Correct Answer: 50

Rationale : A reading of 20/50 means that the patient can see at 20 feet what the normal eye can see at 50 feet.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 27

Type: MCMA

The nurse is assessing CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). Which eye movements would the nurse document as nystagmus?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patients eyes move together through the six cardinal positions of gaze.

2. The patients eyes jerk horizontally instead of moving smoothly.

3. The patients eyes move in a rotary fashion when attempting to follow the examiners finger.

4. The patients eyes cross when following the examiners finger.

5. The patients eyelids droop when the eye is moved to the left.

Correct Answer: 2,3

Rationale 1: This is a normal finding and is not considered nystagmus.

Rationale 2: Nystagmus may be a horizontal movement.

Rationale 3: Nystagmus can be a rotary movement.

Rationale 4: Crossing of the eyes is a dysconjugate gaze.

Rationale 5: Drooping of the eyelid is ptosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 28

Type: MCSA

A patient was admitted to the emergency department after falling at work. The nurse assesses that the patients left pupil has a slightly oval shape. What nursing action is indicated?

1. Notify the physician immediately.

2. Document this finding as anisocoria.

3. Document a normal finding

4. Plan to reassess the pupils in a darker room.

Correct Answer: 1

Rationale 1: Oval shaping of one pupil can indicate potential brain stem herniation. The physician should be notified immediately.

Rationale 2: Anisocoria is unequal pupil size without pathology. The nurse cannot be certain there is no pathology.

Rationale 3: This is not a normal finding.

Rationale 4: Reassessment is not necessary.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 29

Type: MCMA

The nurse detects an abnormality in CN VIII (facial) during a neurological assessment. Which interventions would the nurse consider?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have the patient wear an eye patch during the day.

2. Check visual acuity with the Snellen chart.

3. Assess pupils for equality of size and response to light.

4. Provide the patient with an eye shield to wear at night.

5. Warn the patient about the possibility of choking when drinking fluids.

Correct Answer: 1,4

Rationale 1: Disruption of CN VII may result in the inability to close the eye. The patient should wear an eye patch to protect the eye from drying out or being injured.

Rationale 2: Visual acuity is provided by CN II and would not be affected by disturbance of CN VII.

Rationale 3: Pupil size and response to light are not controlled by CN VII.

Rationale 4: Disruption of CN VII may result in the inability to close the eye. The patient should wear an eye patch or shield to protect the eye from drying out or being injured at night.

Rationale 5: CN VII dysfunction is not associated with choking.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-3

Question 30

Type: FIB

The nurse assesses that a patient is able move her left arm but uses her right arm to assist. The nurse would assign the affected muscle group a strength grade of ______.

Standard Text:

Correct Answer: 2

Rationale : When a patient can move a muscle with support against gravity, the muscle strength grade assigned is 2.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

 

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