When the nurse collects objective data, which finding requires immediate follow-up?

Moist nasal mucosa

Cerumen in the ear

Enlarged lymph node in the neck

Acne lesions on the face and upper chest

Answer and Explanation

The Correct Answer is C

A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

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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. Wait until the end of the physical assessment to reassess the radial pulse. B. Reassess the client's pedal pulse on the other foot. C. Assess the client's 51 and 52 sounds for regularity. D. Assess the client's apical pulse for a full minute.

Correct Answer is ["A","D"]

Explanation

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

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When the nurse collects objective data, which finding requires immediate follow-up?

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

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

The nurse is assessing a client's cardiovascular status within the comprehensive health history. What should the nurse include in this section of the assessment? (Select all that apply.)

Cranial nerves involved in eye movements are:

Which type of assessment includes a health history and physical assessment?

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

Use of tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma.

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

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?