Medical surgical nursing 12th edition

.The nurse is collecting data and has just completed the Weber test on a patient with normal findings. How should the nurse correctly document the findings? 1. BC greater that A3 2. Left and right ear heard equally 3. Left ear heard better than right ear 4. Air conduction greater than bone conduction(BC) - Rationale-2. Left and right ear heard equally 2.The nurse performs a Snellen chart examination on a patient. What snellen chart documentation indicates normal vision for the patient? 1. Left eye 80/20 2. Left eye 20/200 3. Both eyes 20/20 4. Right eye 200/20 - Rationale-3. Both eyes 20/20 3.The nurse has reinforced teaching with a patient after diagnostic testing reveals tinnitus. Which patient statement indicates that teaching has been effective? 1. there is a toxic substance in my ear 2. that is why i have so much discharge all of the time 3. my ear pain should get better if i follow the doctors orders 4. the ringing sound i hear in my ear may be a symptom of another problem - Rationale-4. the ringing sound i hear in my ear may be a symptom of another problem 5.The nurse palpates a downward small protrusion the helix of a patients ear known as Darwins tubercle. How should the nurse document this finding? 1. A tumor 2. Within normal limits 3. A lump filled with fluid 4. An abnormal palpable calcification - Rationale-2. Within normal limits 6.The nurse is conducting an initial screening to determine a patients gross hearing acuity as part of a complete physical. Which test should the nurse include in the assessment? 1. Romberg 2. Calorie test 3.Whisper test 4. Otoscopic examination - Rationale-3.Whisper test 7.After collecting data the nurse suspects a patient has hearing loss. Which finding supports this conclusion? 1. Converses easily with the nurse 2. Answers questions appropriately 3. Speaks in an unusually loud voice 4. Relaxes facial features during conversation - Rationale-3. Speaks in an unusually loud voice 8.The nurse is caring for a patient who asks what arcus senilis is. How should the nurse explain this findings? 1. An eye infection 2. A mental condition 3. A drooping of the eyelid 4. A lipid deposit in the cornea - Rationale-4. A lipid deposit in the cornea 9.The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which equipment should the nurse expect to be used? 1. a tonometer 2. ultrasonography 3. an ophthalmoscope 4. a slit-lamp microscope - Rationale-1. a tonometer 10.A patient ask how the ears are able to equalize pressure when flying in an airplane. Which anatomical ear structure should the nurse review with the patient? s 2. auricle 3. cochlea 4. eustachian tubes - Rationale-4. eustachian tubes 11.The nurse is caring for a patient who ask the nurse, What part of the eye gives the eye its color? What is the correct response by the nurse? 1. iris 2. lens 3. pupil a - Rationale-3. pupil 12.The nurse is reviewing the structure of the eye with a patient scheduled for cataract surgery. Which structure should the nure explain is the gelatin-like substance that gives shape to the eye and fills the space behind the lens? 1. conjunctiva 2. lacrimal fluid 3. vitreous humor 4. aqueous humor - Rationale-3. vitreous humor 13.The nurse is assisting with health screening in a clinic. Which should the soft nurse consider a normal finding if noted lining the ear canal? 1. mucus 2. cerumen 3. perilymph 4. endolymph - Rationale-2. cerumen 14.The nurse is testing a patients peripheral visual ability. What technique should the nurse use? 1. cover test 2. visual fields 3. corneal light reflex test 4. six cardinal fields of gaze - Rationale-2. visual fields 15.The nurse performs a visual assessment on a patient and documents . the findings using the acronym PERRLA. What does PERRLA indicare? 1. palperbral angle rigid, right and left angles 2. patients eyes round, regular, lively, active 3. pupils equilateral, regular, round, little accommodation 4. pupils equal, round, and reactive to light and accommodation - Rationale-4. pupils equal, round, and reactive to light and accommodation 16.The nurse is collecting data visually on a patient. Which lighting environment should the nurse use to examine the patients pupils? 1. natural lighting 2. brightly lit room 3. slightly darkened room 4. completely darkened room - Rationale-3. slightly darkened room 17.The nurse is testing a patients visual muscle balance and movement. What technique should the nurse use to gather this data? 1. visual fields 2. direct pupillary reflex