A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available?

Tuning fork

Stethoscope

Ophthalmoscope

Tongue depressor

Answer and Explanation

The Correct Answer is A

A. Tuning fork: A tuning fork is used in auditory assessments, such as hearing tests, to evaluate hearing loss and bone conduction.

B. Stethoscope: While a stethoscope is essential for auscultation of heart and lung sounds, it is not used for examining the ears.

C. Ophthalmoscope: An ophthalmoscope is used for examining the eyes, not the ears.

D. Tongue depressor: A tongue depressor is used for examining the mouth and throat, not the ears.

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Correct Answer is C

Explanation

A. Diverticulosis: This condition involves the formation of pouches in the colon and is not associated with Murphy's sign.

B. Nephrolithiasis: This refers to kidney stones and is not associated with Murphy's sign.

C. Acute Cholecystitis: Murphy's sign is a clinical test for acute cholecystitis, which is inflammation of the gallbladder. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.

D. Appendicitis: Appendicitis is an inflammation of the appendix and is not related to Murphy's sign.

A. History of present illness B. Initial Information C. Review of Systems D. Health Patterns

Correct Answer is A

Explanation

A. History of present illness: The OLD CART mnemonic is used to evaluate the characteristics of a symptom, which is documented under the history of present illness.

B. Initial Information: This section includes basic demographic and background information rather than detailed symptom analysis.

C. Review of Systems: This section includes a systematic review of body systems and their functions, not the detailed attributes of a specific symptom.

D. Health Patterns: This section covers the client’s overall health patterns and lifestyle but not the detailed attributes of a specific symptom.

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A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A positive Murphy's sign is indicative of?

Correct Answer is C

Explanation

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

Correct Answer is A

Explanation

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