301 Exam III Marathon

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?

• Audiometry

• Rinne

• Whisper

• Weber's

The nurse is preparing a client for a head-to-toe examination. Which of the following should the nurse do at this time? Select all that apply.

• Explain your respect for the client's privacy and for confidentiality

• Formulate nursing diagnoses

• Explain that the client will need to change into a gown

• Discuss the purpose and importance of the health history with the client

• Acquire the client's permission to ask personal questions

The nurse has been ordered to include an ear assessment as part of a head-to-toe examination of a client. Which of the following pieces of equipment will the nurse need for this assessment?

• Snellen chart

• Ophthalmoscope

• Stethoscope

• Otoscope

Which technique should the nurse use to examine the sinuses of a client with a sinus infection?

• Insert a penlight into the oral cavity and angle towards the roof of the mouth

• Indirectly percuss over the cheekbones for dullness or pain

• Inspect the frontal and maxillary sinuses with an otoscope

• Press up on the brow on each side of the nose to palpate the frontal sinuses

An elderly client diagnosed with sinusitis undergoes a transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which precaution should the nurse take to avoid an inaccurate result?

• Dim the lights in the room during examination

• Instruct the client to remove upper dentures

• Hold the light source below the eyebrow

• Lightly tap with fingers over the maxillary sinus

Which characteristic of the gums should a nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment?

• A grey-white line

• Pink, moist, firm

• Red, bleeding

• Enlarged, reddened

Which assessment of the tongue should the nurse recognize as abnormal?

• Ventral surface with visible veins

• Red with loss of papillae

• Pale pink and moist

• Fissured, topographical pattern

A client is brought to the emergency department in a confused state. Upon examination of the client's mouth, the nurse detects a fruity odor to the breath. The nurse recognizes that this finding is characteristic of what disease process?

• Small-bowel obstruction

• respiratory infection

• Diabetic ketoacidosis

• End-stage liver disease

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

• Ask the client to read the Snellen chart

• Test the cornea of the eye with an ophthalmoscope

• Shine a penlight on the eye in a darkened room

• Touch the cornea with a wisp of cotton

A nurse performs the cover test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse should observe for which response to indicate a normal finding?

• Covered eye moves to establish focus

• Both eyes may turn either downward or upward

• Covered eye remains fixed straight ahead

• Uncovered eye turns inward to establish focus