Exam 22: Health Assessment

The left pupil of a patient fails to accommodate.This finding may reflect an abnormality in which cranial nerve?

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee.The nurse observes active motion against some,but not against full,resistance.How should the nurse document this finding?

The nurse on a medical unit notes a moderate amount of fluid accumulation in the feet and ankles of a 75-year-old patient.The nurse will further assess this patient for indications of which conditions? Select all that apply.

An 85-year-old patient is brought to the emergency department with lethargy and hypotension.When the nurse assesses the patient's tongue,she notes that it appears dry and furry.This finding suggests:

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse.This finding is associated with:

The nurse assesses a 4-year-old child's vision as 20/40.This finding is considered:

A mother brings her 6-month-old infant to the clinic for a well-baby checkup.How should the nurse proceed when weighing the patient?

Which disorder(s)might limit a patient's visual field? Select all that apply.

While the nurse assesses a newborn of African American descent,the mother points out a blue-black Mongolian spot on the newborn's back and asks,"What's that? Is something wrong with my baby?" Which response by the nurse is best?

The nurse is concerned that an African American client is experiencing cyanosis.Which of the following signs of cyanosis would the nurse look for in this client?

The nurse is bathing a newborn infant in the nursery and notices scaly white patches over the infant's scalp.What is the most appropriate action by the nurse?

A patient's jugular venous pressure measures 5 cm.This finding indicates:

The nurse notes ptosis in a patient who just arrived in the emergency department.The nurse quickly triages the patient because she knows that this finding,along with other symptoms,might suggest:

Which portion of the ear is responsible for maintaining equilibrium?

When testing near vision,the nurse should position printed text how many inches away from the patient?

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea?

The nurse notes an S₃ heart sound while performing an assessment on a patient admitted with an acute myocardial infarction.The nurse notifies the physician of the finding,which most likely suggests:

A 48-year-old patient comes to the physician's office complaining of diminished near vision,which the nurse confirms with testing.She should document this finding as:

An older adult's fingernails appear concave and spoon shaped.The nurse associates this observation with:

The nurse is assessing the level of consciousness of a client who suffered a head injury.She uses the Glasgow Coma Scale and determines that the client's score is 15.Which responses did the nurse assess in this client? Select all that apply.