NUR 2092 Health Assessment Exam 2 Study Guide Nurses collect objective data when performing patient assessments.What is an example of objective data? (Answer)- It's data that can be collected through assessment.
Example: swelling/inflammation, skin temperature, discoloration, brittle
hair/nails, etc.The nurse is assessing an adult who has a pulse rate of 180 beats/minute.What is this? (Answer)- Tachycardia; an abnormally high/rapid heart rate Abnormal respiration sounds heard during auscultation characterized by discontinuous bubbling sounds heard over the distal bronchioles and
alveoli that contain serous secretions are: (Answer)- Crackles (also
known as rales) The period of time within the cardiac cycle in which the ventricles are
relaxed and filling with blood: (Answer)- Diastole/diastolic
The client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do what to ensure client safety?(Answer)- Speak loudly to the patient, test the temperature of food/water/shower, clear path for ambulation without obstacles The nurse is testing the coordination function of cranial nerves III, IV,
and VI. To do this correctly, the nurse would test: (Answer)- eye
movement by using the whisker test (having the patient follow an object with their eyes in the shape of whiskers, without moving their head) and pupillary response (looking at the diameter of the pupils in normal lighting and direct bright light) 1 / 2
The nurse is planning to test the function of the trigeminal nerve (CN V). The nurse would gather which items to perform this test? (Answer)- A piece of cotton or blunt object to touch the patient's face lightly (to test their sensory function) The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which to test the client's peripheral response to pain? (Answer)- Nail bed pressure Providing resistance while the patient shrugs his/her shoulders is a test of which of the cranial nerves? (Answer)- Accessory (CN XI)
Visual acuity is assessed by: (Answer)- Snellen chart (a chart with
different sized letters) and near vision test (a card with various sized letters held at a certain distance) The six eye muscles that control eye movement are innervated by cranial
nerves: (Answer)- -Oculomotor (CN III)
-Trochlear (CN IV) -Abducens (CN VI) Documentation of an eye examination can include the term PERRLA.What does this stand for? (Answer)- Pupil equal, round, reactive to light, and accommodation Which assessment best confirms symmetric chest expansions?(Answer)- Placing warm hands on the posterior-lateral chest wall with thumbs at T9/T10. Sliding the hands up medially to pinch a small fold of skin between your thumbs. Ask the patient to take a deep breath; you thumbs should move apart symmetrically
Absence of diaphragmatic excursion occurs with: (Answer)- -When the
bronchial tree is obstructed at some point by secretions, a mucous plug, or foreign body
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