Author Question: A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? ... (Read 114 times)

jwb375 · **on:** Jul 22, 2018

A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? (Select all that apply.)

a. Orthopnea
b. Nonpalpable lymph nodes
c. Pleural friction rub present
d. Crackles in lower lung lobes
e. Grade 5 muscle function level
f. A 160-degree angle between nail plate and nail

Question 2

A nurse is assessing a patient's cranial nerve IX. Which items does the nurse gather before conducting the assessment? (Select all that apply.)

a. Vial of sugar
b. Snellen chart
c. Tongue blade
d. Ophthalmoscope
e. Lemon applicator

ricroger · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A, C, D
Abnormal findings will cause a nurse to follow up. Orthopnea is abnormal and indicates cardiovascular or respiratory problems. Pleural friction rub is abnormal and indicated an inflamed pleura. Crackles are adventitious breath sounds and indicate random, sudden reinflation of groups of alveoli, indicating disruptive passage of air through small airways. Lymph nodes should be nonpalpable; palpable lymph nodes are abnormal. Grade 5 muscle function is normal. A 160-degree angle between nail plate and nail is normal; a larger degree angle is abnormal and indicates clubbing.

Answer to Question 2

ANS: A, C, E
Cranial nerve IX is the glossopharyngeal, which controls taste and ability to swallow. The nurse asks the patient to identify sour (lemon) or sweet (sugar) tastes on the back of the tongue and uses a tongue blade to elicit a gag reflex. Ophthalmoscopes are used for vision. A Snellen chart is used to test cranial nerve II (optic).