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?

Apparent state of health

Facial expression

Level of consciousness

Posture, gait, motor activity, and speech

Answer and Explanation

The Correct Answer is C

A. Apparent state of health: This generally reflects overall health rather than specific mental or cognitive status.

B. Facial expression: Facial expression provides insight into mood and emotional state but does not specifically assess consciousness or orientation.

C. Level of consciousness: Being awake, alert, and oriented is directly related to the level of consciousness, which is a key aspect of assessing cognitive and mental function.

D. Posture, gait, motor activity, and speech: These aspects are relevant for physical activity and motor skills, not specifically for consciousness or cognitive orientation.

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Correct Answer is A

Explanation

A. VII: The Facial nerve (VII) is responsible for taste sensation in the anterior two-thirds of the tongue. An inability to taste in this area indicates a dysfunction in this nerve.

B. XII: The Hypoglossal nerve (XII) controls tongue movements but does not involve taste sensation.

C. V: The Trigeminal nerve (V) provides sensation to the face and mouth but is not responsible for taste.

D. II: The Optic nerve (II) is involved in vision, not taste.

A. Wheezes B. Rhonchi C. Coarse crackles (rales) D. No sound

Correct Answer is C

Explanation

A. Wheezes: Wheezes are high-pitched sounds usually associated with airway constriction, such as in asthma, not specifically lobar pneumonia.

B. Rhonchi: Rhonchi are low-pitched, snoring sounds associated with secretions in the airways and may be present in pneumonia but are not the most characteristic finding.

C. Coarse crackles (rales): Coarse crackles or rales are bubbling, crackling sounds heard when air moves through fluid in the airways, which is typical in pneumonia due to the presence of alveolar fluid.

D. No sound: Absence of sound is not expected in pneumonia; adventitious sounds like crackles are usually present.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is unable to taste in the 2/3 anterior of his tongue. Which cranial nerve is affected?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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