ATI ASN Physical Assessment NSG1530 Foundational Physical Assessment Exam 2 .
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Free ATI ASN Physical Assessment NSG1530 Foundational Physical Assessment Exam 2 . Questions
Which of the following best describes exophthalmos?
- Inward turning of the eyelid margin toward the eyeball
- Drooping of the upper eyelid due to muscle weakness
- Bulging or protrusion of the eyeball
- Constriction of the pupil in response to light
Explanation
Correct Answer: C) Bulging or protrusion of the eyeball
Exophthalmos, also known as proptosis, refers to the abnormal bulging or forward protrusion of one or both eyeballs from the eye socket. It is most commonly associated with Graves' disease, a form of hyperthyroidism, where inflammation and swelling of the orbital tissues push the eye forward. Option A describes entropion. Option B describes ptosis, which is associated with Cranial Nerve III dysfunction or myasthenia gravis. Option D describes a normal pupillary response to light, not a structural eye abnormality.
The nurse performs an eye assessment. Which of the following indicates an expected finding of cranial nerve III (oculomotor) function?
- Eyelids close tightly
- Pupils constrict in response to light
- Client reads print at 14 inches
- Pupils dilate in response to light
Explanation
Correct Answer: B) Pupils constrict in response to light
Cranial Nerve III, the Oculomotor nerve, controls pupillary constriction, upper eyelid elevation, and most extraocular eye movements. The expected normal finding when testing this nerve is pupillary constriction in response to direct light. Eyelid closure is controlled by Cranial Nerve VII. Reading print at 14 inches tests visual acuity assessed by Cranial Nerve II. Pupillary dilation is an abnormal finding indicating Cranial Nerve III dysfunction or increased intracranial pressure.
A student nurse asks what PERRLA stands for. Which answer by the nurse demonstrates the correct explanation of PERRLA?
- Pupils are Elevated and Round and Red to Link and Association
- Pupils are Extended and Round and Responsive to Lactic and Application
- Pupils are Edged and Round and Raised to Lacunar and Activation
- Pupils are Equal and Round and React to Light and Accommodate
Explanation
Correct Answer: D) Pupils are Equal and Round and React to Light and Accommodate
PERRLA is a standard acronym used in neurological and eye assessments to document normal pupil findings. Each letter represents a specific characteristic: Pupils are Equal in size, Round in shape, and Reactive to Light — meaning they constrict when light is shone into them — and Accommodate — meaning they constrict when focusing on a near object. This assessment is critical in evaluating the function of Cranial Nerve III and detecting neurological changes such as increased intracranial pressure or brain herniation.
The nurse is preparing to perform the Romberg test on a client. Which of the following actions should the nurse take?
- Instruct client to touch their finger to nose
- Ask the client to shrug their shoulders against resistance
- Ask the client to repeat a common phrase
- Instruct client to stand with feet together, close their eyes, and observe for swaying
Explanation
Correct Answer: D) Instruct client to stand with feet together, close their eyes, and observe for swaying
The Romberg test is a neurological assessment used to evaluate balance and proprioception by testing the client's ability to maintain equilibrium without visual input. The nurse instructs the client to stand with feet together and arms at the sides, then close their eyes while the nurse observes for swaying or loss of balance. Excessive swaying or falling with eyes closed indicates a positive Romberg sign, suggesting cerebellar dysfunction or impaired proprioception.
A nurse is assessing for cyanosis on a client with darker pigmented skin. Which area provides the best site for evaluation?
- Oral mucosa
- Ears
- Abdomen
- Palms of the hands
Explanation
Correct Answer: A) Oral mucosa
In clients with darker pigmented skin, cyanosis cannot be reliably detected by examining the skin surface as melanin masks color changes. The oral mucosa, particularly the lips and gums, contains less melanin and has highly vascularized tissue close to the surface, making it the most reliable site to detect the bluish discoloration of cyanosis regardless of skin tone. The conjunctiva and nail beds are also acceptable alternative sites.
A client drank a volume of 6 ounces (oz) of orange juice. How would the nurse document the volume in milliliters (mL)?
Explanation
Explanation
The standard conversion for fluid measurement is 1 ounce equals 30 milliliters. Therefore, to convert 6 ounces to milliliters: 6 oz × 30 mL = 180 mL. This conversion is essential for accurate intake and output documentation in clinical nursing practice.
A nurse asks a client who has facial droop to close both eyes tightly and smile. Which cranial nerve is the nurse assessing?
- Cranial nerve III (oculomotor)
- Cranial nerve XII (hypoglossal)
- Cranial nerve VII (facial)
- Cranial nerve V (trigeminal)
Explanation
Correct Answer: C) Cranial nerve VII (facial)
Cranial Nerve VII, the Facial nerve, controls all muscles of facial expression including the ability to close the eyes tightly and smile. Assessing a client with facial droop by asking them to perform these movements directly tests the integrity of this nerve.
Dysfunction of Cranial Nerve VII results in asymmetrical facial movements, inability to fully close the eye, and drooping of the mouth on the affected side as seen in Bell's palsy or stroke. Cranial Nerve III controls eye movement and pupil constriction, Cranial Nerve XII controls tongue movement, and Cranial Nerve V controls facial sensation and mastication.
A nurse is caring for a client who reports chronic pain but appears calm and does not request medication. Which factors may contribute to the client's underreporting of pain? (Select All that Apply.)
- Desire to receive stronger pain medication
- Belief that pain is a normal part of aging
- Preference for non-pharmacological pain relief
- Fear of becoming dependent on pain medication
- Cultural norms that discourage expression of pain
Explanation
Correct Answer: B) Belief that pain is a normal part of aging, C) Preference for non-pharmacological pain relief, D) Fear of becoming dependent on pain medication, E) Cultural norms that discourage expression of pain
Multiple factors can cause clients to underreport pain. Older adults commonly believe pain is an inevitable part of aging and therefore do not report it. Some clients prefer non-pharmacological methods such as heat, massage, or relaxation techniques and may not request medication as a result. Fear of opioid dependence or addiction is a well-documented barrier to adequate pain reporting and management. Cultural backgrounds that value stoicism or discourage verbal expression of pain significantly influence how clients communicate their pain experience.
When assessing eye movement with the six cardinal fields of gaze, the nurse understands which of the following cranial nerves are being assessed?
-
Cranial nerves I, II, and IV
-
Cranial nerves I, II, and VII
-
Cranial nerves IV, V, and IX
-
Cranial nerves III, IV, and VI
Explanation
Correct Answer: D) Cranial nerves III, IV, and VI
The six cardinal fields of gaze test the extraocular muscles and the three cranial nerves that control eye movement. Cranial Nerve III (Oculomotor) controls most eye movements including upward, downward, and medial gaze. Cranial Nerve IV (Trochlear) controls downward and inward eye movement. Cranial Nerve VI (Abducens) controls lateral or outward eye movement. Together these three nerves coordinate all directions of eye movement assessed during the six cardinal fields of gaze examination.
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve IX?
- Use a tongue depressor to elicit gag reflex.
- Assess pupil reaction using a penlight.
- Have the patient smile.
- Ask client to read from a Snellen chart.
Explanation
Correct Answer: A) Use a tongue depressor to elicit gag reflex.
Cranial Nerve IX, the Glossopharyngeal nerve, is responsible for the sensory component of the gag reflex, taste on the posterior one-third of the tongue, and swallowing. Using a tongue depressor to touch the posterior pharynx and elicit the gag reflex directly tests the integrity of Cranial Nerve IX, along with Cranial Nerve X which provides the motor response. Assessing pupil reaction tests Cranial Nerve III. Having the patient smile tests Cranial Nerve VII. Reading from a Snellen chart tests Cranial Nerve II visual acuity.
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