Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

Use of accessory muscles

Nail bed greater than 160 degrees

Circumoral cyanosis

Pursed lip breathing

Anteroposterior-to-transverse diameter of 1:1

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

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Correct Answer is D

Explanation

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

A. Frenulum B. Palate C. Uvula D. Papillae.

Correct Answer is A

Explanation

A. Frenulum:

The frenulum is a thin band of tissue in the mouth that connects the tongue to the floor of the mouth. It aids in the tongue's movement and flexibility during speaking and swallowing.

B. Palate:

The palate refers to the roof of the mouth. It has two parts: the hard palate (at the front, made of bone) and the soft palate (at the back, made of muscle). The palate plays a crucial role in speech and swallowing.

C. Uvula:

The uvula is a small, fleshy extension at the back of the soft palate in the mouth. It participates in various functions, including speech articulation, preventing food from entering the nasal cavity during swallowing, and producing certain sounds.

D. Papillae:

Papillae are small, raised structures on the tongue that contain taste buds. They are responsible for detecting different tastes: sweet, salty, sour, bitter, and umami (savory). Papillae give the tongue its rough texture.

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Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Correct Answer is D

Explanation

The nurse is performing an assessment of the client's mouth. The nurse recognizes that the tissue that connects the tongue to the floor of the mouth is the:

Correct Answer is A

Explanation

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