N3153 Dallas Health Assessment Exam 3 SP26
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Free N3153 Dallas Health Assessment Exam 3 SP26 Questions
The nurse asks for the patient to stick out their tongue. The tongue protrudes midline. What does this finding indicate?
- Loss of function CN XII
- Intact CN XII
- Loss of function of CN IX
- Intact CN IX
Explanation
Explanation:
Correct Answer: (B) Intact CN XII
Cranial Nerve XII, the hypoglossal nerve, controls the movement of the tongue. When a patient protrudes their tongue and it extends straight out along the midline, this indicates that the hypoglossal nerve is functioning bilaterally and symmetrically. A deviation of the tongue to one side upon protrusion would suggest damage or weakness of CN XII on the side toward which the tongue deviates.
Why Other Options are Incorrect:
A. Loss of function CN XII — Loss of CN XII function would cause the tongue to deviate toward the affected side upon protrusion, not extend midline. A midline tongue indicates normal CN XII function.
C. Loss of function of CN IX — CN IX, the glossopharyngeal nerve, is responsible for taste sensation on the posterior third of the tongue, swallowing, and the gag reflex. It does not control tongue protrusion and is not assessed by this maneuver.
D. Intact CN IX — While CN IX may indeed be intact, this specific assessment of tongue protrusion tests CN XII, not CN IX. Midline protrusion does not provide information about the status of CN IX.
A nurse is caring for a 78-year-old patient with end-stage heart failure on contact precautions for MRSA. The patient is wearing a purple DNR bracelet and has an advance directive stating "comfort measures only." The patient's oxygen saturation drops to 85%, and the patient becomes increasingly short of breath. Which action should the nurse take first?
- Don a gown and gloves, enter the room, and assess the patient's comfort level and provide oxygen and morphine as ordered.
- Call a Code Blue and initiate CPR per hospital protocol.
- Document the patient's condition.
- Contact the healthcare provider to discuss transferring the patient to the intensive care unit.
Explanation
Explanation:
Correct Answer: (A) Don a gown and gloves, enter the room, and assess the patient's comfort level and provide oxygen and morphine as ordered.
The patient has a valid DNR order and an advance directive specifying comfort measures only. The nurse's primary obligation is to honor these directives while providing compassionate care. Because the patient is on contact precautions for MRSA, the nurse must first don appropriate PPE before entering the room. Providing oxygen and morphine as ordered addresses breathlessness and ensures the patient's comfort in alignment with their expressed wishes.
Why Other Options are Incorrect:
B. Call a Code Blue and initiate CPR per hospital protocol — This directly violates the patient's DNR order and advance directive. Initiating CPR would be both ethically and legally inappropriate in this situation.
C. Document the patient's condition — Documentation is important but is not the first priority. The patient is in active distress and requires immediate comfort-focused intervention before documentation.
D. Contact the healthcare provider to discuss transferring the patient to the ICU — Transferring a comfort-measures-only patient to the ICU contradicts their advance directive and is not aligned with their goals of care.
The nurse is preparing to assess a 2-year-old child's ears. Which technique is appropriate for visualizing the tympanic membrane?
- Pull the pinna down and back
- Pull the pinna up and back
- Pull the pinna down and forward
- Pull the pinna up and forward
Explanation
Explanation:
Correct Answer: (A) Pull the pinna down and back
In children under 3 years of age, the ear canal curves upward, so the pinna must be pulled down and back to straighten the canal and allow proper visualization of the tympanic membrane with the otoscope. This technique differs from the approach used in adults.
Why Other Options are Incorrect:
B. Pull the pinna up and back — This is the correct technique for adults and older children, not for children under 3 years of age whose ear canal has a different anatomical orientation.
C. Pull the pinna down and forward — Pulling the pinna forward does not straighten the ear canal and would obstruct visualization of the tympanic membrane.
D. Pull the pinna up and forward — This direction neither straightens the canal nor follows any evidence-based technique for otoscopic examination in any age group.
The registered nurse working in a COVID-19 triage unit reads vital signs taken by the patient care technician (PCT). Which patient should the nurse assess first?
- Mr. Grey: T 37.3°C P 96 R 18 BP 138/90 O2 Sat 97%
- Mr. Silver: T 37.4°C P 108 R 14 BP 102/74 O2 Sat 95%
- Mr. Green: T 36.8°C P 96 R 28 BP 118/68 O2 Sat 92%
- Mr. Brown: T 38°C P 100 R 16 BP 120/78 O2 Sat 99%
Explanation
Explanation:
Correct Answer: (C) Mr. Green: T 36.8°C P 96 R 28 BP 118/68 O2 Sat 92%
Mr. Green presents with a respiratory rate of 28 breaths per minute (tachypnea) and an oxygen saturation of 92%, both of which are critically abnormal, especially in a COVID-19 setting where respiratory compromise is the primary concern. Low O2 saturation combined with tachypnea signals impending respiratory failure and demands immediate assessment and intervention.
Why Other Options are Incorrect:
A. Mr. Grey — His vital signs are largely within normal limits. A slightly elevated blood pressure of 138/90 and O2 sat of 97% do not indicate an immediate emergency.
B. Mr. Silver — While his pulse of 108 is mildly elevated and O2 sat of 95% is slightly low, these findings are less critical compared to Mr. Green's respiratory distress indicators.
D. Mr. Brown — His temperature is slightly elevated but his O2 sat is 99% and all other vitals are within acceptable range, posing no immediate threat.
Patients with chronic allergies may have small, pale, round, firm overgrowths on the nasal mucosa. Which term should be used to describe this physical assessment finding?
- Perforated septum
- Chronic sinusitis
- Polyps
- Turbinates
Explanation
Explanation:
Correct Answer: (C) Polyps
Nasal polyps are small, pale, round, firm, noncancerous growths that develop on the lining of the nasal mucosa. They are commonly associated with chronic allergies, asthma, and recurrent sinus inflammation. Their pale color and smooth, round shape distinguish them from other nasal structures during physical assessment.
Why Other Options are Incorrect:
A. Perforated septum — A perforated septum refers to a hole in the nasal septum and is not described as an overgrowth on the mucosa.
B. Chronic sinusitis — Chronic sinusitis is an inflammatory condition of the sinuses, not a physical structure or growth visualized on the nasal mucosa.
D. Turbinates — Turbinates are normal bony structures within the nasal cavity that help filter and humidify air. They are not overgrowths and are not abnormal findings.
The nurse inspects the patient's eyes. Which condition is most concerning?
- Arcus senilis.
- Yellow sclera.
- Subconjunctival hemorrhage.
- Pingueculae.
Explanation
Explanation:
Correct Answer: (B) Yellow sclera.
Yellow sclera (scleral icterus) indicates jaundice, which is caused by elevated bilirubin levels in the blood. This is a significant clinical finding that suggests underlying pathology such as liver disease, biliary obstruction, or hemolytic anemia, all of which require prompt medical evaluation and intervention.
Why Other Options are Incorrect:
A. Arcus senilis is a white or grayish ring around the cornea caused by lipid deposits; it is a benign, age-related finding in older adults and does not require urgent concern.
C. Subconjunctival hemorrhage is a collection of blood under the conjunctiva that appears as a bright red patch on the white of the eye; it is typically benign and self-resolving, most often caused by straining, coughing, or minor trauma.
D. Pingueculae are benign yellowish deposits of protein and fat on the conjunctiva, typically adjacent to the cornea; they are harmless and do not indicate systemic disease.
A nurse is receiving bedside shift report on four assigned patients. Using clinical judgment and priority-setting principles, which patient requires the nurse to assess first?
- A 55-year-old patient with an acute kidney injury (AKI) whose morning potassium level is 5.1 (normal 3.5-5.0) and who is waiting for the stat dose of sodium polystyrene sulfonate (Kayexalate) to be delivered from the pharmacy.
- A 72-year-old patient 4 hours post-percutaneous coronary intervention (PCI) with a non-bleeding groin puncture site and a reported dull, constant backache rated 4/10.
- A 45-year-old patient with a history of seizures who missed the 0600 dose of phenytoin (Dilantin) because it was held for a critically low albumin level.
- A 60-year-old patient with chronic obstructive pulmonary disease (COPD) and a tracheostomy whose heart rate is 105/min (baseline 88/min) and whose family member reports a sudden increase in noisy respirations.
Explanation
Explanation:
Correct Answer: (D) A 60-year-old patient with COPD and a tracheostomy whose heart rate is 105/min and whose family member reports a sudden increase in noisy respirations.
This patient presents with an acute change in respiratory status — noisy respirations, tachycardia above baseline, and a tracheostomy, which is a high-risk airway. A sudden increase in noisy breathing in a tracheostomy patient may indicate a mucus plug, partial obstruction, or tracheostomy displacement, all of which can rapidly progress to complete airway obstruction and respiratory arrest. This is an immediate life threat requiring the nurse's first assessment.
Why Other Options are Incorrect:
A. The AKI patient with a potassium of 5.1 has mild hyperkalemia slightly above the normal range. While monitoring is warranted, this is not an immediate emergency compared to an acute airway compromise.
B. A non-bleeding groin site with a mild backache post-PCI requires monitoring but does not indicate an immediately life-threatening complication at this time.
C. A missed dose of phenytoin is concerning for seizure risk, but the patient is not currently seizing. This warrants timely attention but is not as immediately critical as an acute airway issue.
When examining the eye, where will the nurse most likely find signs of liver disease?
- Macula
- Cornea
- Sclera
- Limbus
Explanation
Explanation:
Correct Answer: (C) Sclera
The sclera, commonly known as the white of the eye, is the most visible location where jaundice associated with liver disease can be detected. When the liver is unable to properly process bilirubin, it accumulates in the body and causes a yellowing of the skin and mucous membranes, most noticeably in the sclera. This finding is referred to as scleral icterus and is one of the earliest and most reliable clinical signs of liver disease or biliary obstruction.
Why Other Options are Incorrect:
A. Macula — The macula is a small area at the center of the retina responsible for sharp central vision. It is an internal structure not directly visible without specialized equipment and is not associated with signs of liver disease.
B. Cornea — The cornea is the clear outer covering of the eye. While it can show findings in certain metabolic conditions such as Wilson's disease (Kayser-Fleischer rings), it is not the primary location where jaundice from liver disease is observed.
D. Limbus — The limbus is the border between the cornea and the sclera and is not the area where signs of liver disease such as jaundice are typically identified during routine eye examination.
The nurse performs the cardinal fields of vision tests on a patient and notes the patient's failure to follow the nurse's finger in the lateral movement of the right eye. In which cranial nerve does the nurse suspect a problem?
- CN III
- CN VI
- CN IV
- CN VII
Explanation
Explanation:
Correct Answer: (B) CN VI.
Cranial Nerve VI, the Abducens nerve, controls the lateral rectus muscle responsible for lateral (outward) movement of the eye. Failure to follow the examiner's finger in the lateral direction indicates weakness or paralysis of this muscle, pointing to a deficit in CN VI.
Why Other Options are Incorrect:
A. CN III (Oculomotor) controls most eye movements including upward, downward, and medial gaze, as well as pupil constriction and eyelid elevation; it is not primarily responsible for lateral gaze.
C. CN IV (Trochlear) controls the superior oblique muscle, which is responsible for downward and inward eye movement, not lateral movement.
D. CN VII (Facial) controls facial expression muscles and has no role in eye movement or lateral gaze.
The nurse talks to a patient who reports eye pain, nausea, vomiting, and halos around lights. Which is the most important action for the nurse to take?
- Assess cranial nerve III (oculomotor)
- Initiate emergency referral
- Assess the corneal light reflex
- Assess for presbyopia
Explanation
Explanation:
Correct Answer: (B) Initiate emergency referral
The combination of eye pain, nausea, vomiting, and halos around lights are classic hallmark symptoms of acute angle-closure glaucoma, which is a medical emergency. Intraocular pressure rises rapidly and can cause permanent vision loss within hours if left untreated. Initiating an emergency referral to an ophthalmologist is the most critical and time-sensitive action the nurse can take.
Why Other Options are Incorrect:
A. Assess cranial nerve III (oculomotor) — While CN III assessment is relevant in some eye conditions, it does not address the urgency of the presenting symptoms nor does it lead to the immediate intervention this patient requires.
C. Assess the corneal light reflex — This test evaluates eye alignment and is used to detect strabismus. It is not relevant to the acute presentation of glaucoma symptoms described here.
D. Assess for presbyopia — Presbyopia is an age-related gradual loss of near vision and does not present with acute pain, nausea, vomiting, or halos, making it an irrelevant assessment in this scenario.
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