Assessment of Ears
A patient reports a sensation of spinning. This symptom is known as:
Vertigo
Which condition is characterized by a gradual loss of central vision?
Macular degeneration
During a physical assessment, a nurse finds a patient’s blood pressure to be 140/90 mmHg. How should this be classified?
Stage II Hypertension
What percussion sound is characterized by a loud, low pitch and a long duration?
Resonance
In the context of skin lesions, what does the term "macule" refer to?
A flat, discolored spot
During an otoscopic examination of a patient's right ear, the nurse notes the location of the cone of light at approximately the 5 o'clock position. What does this finding indicate?
The tympanic membrane is intact and positioned normally in the right ear.
Which conditions can cause increased intraocular pressure?
Glaucoma
A patient presents with a heart rate of 120 bpm. This condition is known as:
Tachycardia
When percussing over the abdomen, which percussion sound would indicate the presence of gas?
Tympany
A lesion that is greater than 1 cm, flat, and usually has a different color than the surrounding skin is referred to as a:
Patch
During the assessment phase of the nursing process, which of the following is the most appropriate initial action when evaluating a patient's ear health?
Inspect the external ear
The presence of a "Hirschberg test" assesses:
Eye alignment
In an emergency situation, what is the first vital sign the nurse should assess?
Pulse
A nurse percusses over a solid organ, such as the liver. Which percussion sound is expected?
Dullness
A patient presents with a raised lesion that is firm to the touch and about 0.5 cm in diameter. What type of lesion is this?
Papule
When documenting findings from an ear assessment, which term is appropriate to describe a normal tympanic membrane?
Pearly gray and intact
What does the nurse assess when testing for visual fields by confrontation?
Peripheral vision
What is a non-invasive method for monitoring heart rate?
Palpation of pulse
Which area of the body would most likely produce a flat sound upon percussion?
Muscle, Bone, and Tumors
A lesion characterized by a raised edge and a central crusting area is likely to be a:
Ulcer
When inspecting the ear with an otoscope, which position should the nurse place the patient's head?
Tilted away from the examiner
When documenting a patient’s visual acuity, the nurse records the result as 20/100. What does this indicate?
The patient can see at 20 feet what a person with normal vision can see at 100 feet.
When assessing vital signs, what is the most appropriate way to assess a pulse in an adult?
Radial artery
In a patient with COPD, the nurse would expect to hear which percussion note?
Hyperresonance
What is the most appropriate nursing action when a patient has a skin ulcer?
Assess for signs of infection