A nurse conducting a physical assessment is observing the clients balance and performing tests

Health Assessment Hesi Practice 2024/25 A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing?

• Cranial nerve II
• Cranial nerve IX
• Cranial nerve VII
• Cranial nerve VIII - ANSWER 4. Cranial nerve VIII

Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance when the client is walking or standing, involve the vestibular portion.A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is preparing to check for stereognosis. Which action should the nurse take to perform this assessment?

• Placing an object in the client's hand and asking the client to identify it
• Tracing a number on the client's hand and asking the client to identify it
• Moving the client's finger up and down and asking the client which way it is being moved
• Making two simultaneous pinpricks on the skin and asking the client to distinguish them -

ANSWER 1. Placing an object in the client's hand and asking the client to identify it Stereognosis is the client's ability to recognize objects placed in his or her hand. 1 / 4

A nurse performing an abdominal assessment of a client is preparing to auscultate for bowel sounds. In which part of the abdomen should the nurse place the stethoscope first?

• Left upper quadrant
• Left lower quadrant
• Right upper quadrant
• Right lower quadrant - ANSWER 4. Right lower quadrant

To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally.A nurse performing a physical assessment of a client is checking the client's mouth and throat.As part of the assessment, the nurse plans to assess the function of cranial nerve XII. What should the nurse ask the client to do as a means of assessing this nerve?

• Frown
• Show the teeth
• Stick out the tongue
• Say "ah" as the tongue is depressed with a tongue blade - ANSWER 3. Stick

out the tongue To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client 2 / 4

protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech.Discontinuous high-pitched crackling sounds heard during inspiration that do not clear with coughing - ANSWER Fine Crackles Loud, low-pitched bubbling and gurgling sounds heard on inspiration (may be present on expiration); may decrease with coughing or suctioning but reappear - ANSWER Coarse Crackles High-pitched, continuous musical sounds heard during inspiration or expiration - ANSWER Wheezing Loud, low-pitched, coarse rumbling sounds heard during inspiration or expiration; may be cleared by coughing - ANSWER Rhonchi Dry, grating quality sounds heard best during inspiration; does not clear with coughing - ANSWER Pleural Friction Rub 3 / 4

Moderately pitched; heard over the major bronchi - ANSWER Bronchovesicular sounds Low-pitched rustling; heard over the peripheral lung fields - ANSWER Vesicular sounds High-pitched, with a harsh, hollow, tubular quality heard over the trachea and larynx - ANSWER Bronchial sounds A nurse preparing to perform a respiratory assessment of an adult client is reading the client's medical record. The nurse sees that the health care provider noted resonance on percussion of the client's posterior chest. What interpretation does the nurse make of this finding?

• The client has normal, healthy lungs.
• The client may have a pneumothorax.
• The client most likely has a lung tumor.
• An excessive amount of air is present in the lungs. - ANSWER 1. The client

has normal, healthy lungs.Resonance on percussion predominates in healthy adult lung tissue.

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