The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

"Is the pain worse on exertion?"

"Is the pain worse when you are lying down?"

"Do you have any pain or discomfort in your chest?"

"Do you have cramping pain?"

Answer and Explanation

The Correct Answer is C

A. "Is the pain worse on exertion?": While this is an important question for assessing cardiac risk, it is secondary to identifying any chest pain.

B. "Is the pain worse when you are lying down?": This question is more relevant for assessing musculoskeletal or gastrointestinal issues rather than cardiac risk.

C. "Do you have any pain or discomfort in your chest?": Chest pain or discomfort is a primary symptom associated with cardiac events, making this the most critical question to ask first.

D. "Do you have cramping pain?": This is not specific enough to determine cardiac risk and is more related to gastrointestinal or muscle-related issues.

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Correct Answer is D

Explanation

A. Mental status examination: This part of the assessment evaluates cognitive functions, not sensory functions related to cranial nerve VIII.

B. Mouth and throat: This area assesses cranial nerves related to swallowing and speech but not the sensory function of cranial nerve VIII.

C. Head and face: This includes assessing cranial nerves related to facial sensation and movement but not the auditory function of cranial nerve VIII.

D. Ears: Cranial nerve VIII, the vestibulocochlear nerve, is responsible for hearing and balance, so assessing sensory function related to this nerve occurs during the examination of the ears.

A. Use tangential lighting. B. Assist the client to a standing position. C. Use perpendicular lighting. D. Focus a penlight on the client's chest.

Correct Answer is C

Explanation

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

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The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

Correct Answer is D

Explanation

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Correct Answer is C

Explanation

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?

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?

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A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?

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Cranial nerves involved in eye movements are:

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