Chapter 26 Health & Physical Assessment In Nursing 3rd Edition

Chapter 26  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCMA
The nurse is reviewing the cranial nerves prior to a PRN shift on a neurological unit. Upon the review, the nurse notes that some of the nerves are exclusively sensory nerves. Which cranial nerves belong to this group?
Standard Text: Select all that apply.
1. Olfactory nerve (cranial nerve I).
2. Optic nerve (cranial nerve II).
3. Trochlear nerve (cranial nerve IV).
4. Trigeminal nerve (cranial nerve V).
5. Facial nerve (cranial nerve VII).
Correct Answer: 1, 2
Rationale 1: The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The optic nerve is a sensory nerve responsible for vision.
Rationale 2: The optic nerve is a sensory nerve responsible for vision. The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell.
Rationale 3: The trochlear nerve is a motor nerve responsible for eye movement. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities.
Rationale 4: The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities.
Rationale 5: The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation. The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities.
Global Rationale: The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision. Mixed nerves are able to receive sensory information and perform physical activities. The trochlear nerve is a motor nerve responsible for eye movement. The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity, and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 26.1: Describe the anatomy and physiology of the neurologic system.
MNL Learning Outcome: 11.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 749

Question 2
Type: HOTSPOT
The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. Based on this data, which area of the brain has been damaged?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 1
Rationale: The frontal lobe of the cerebrum is responsible for the control of emotions.
Global Rationale: The frontal lobe of the cerebrum is responsible for the control of emotions.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 26.1: Describe the anatomy and physiology of the neurologic system.
MNL Learning Outcome: 11.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 746

Question 3
Type: HOTSPOT
The nurse is caring for a client with a traumatic brain injury (TBI). The client begins to experience bradycardia. Which area of the brain is likely responsible for the changes in heart rate?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 4
Rationale: The brain stem is responsible for control of the vital signs.
Global Rationale: The brain stem is responsible for control of the vital signs.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 26.1: Describe the anatomy and physiology of the neurologic system.
MNL Learning Outcome: 11.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 747

Question 4
Type: MCSA
The nurse is assessing a client to determine tremors associated with Parkinson disease. Which clinical manifestation does the nurse anticipate during the assessment?
1. Fasciculations.
2. Chorea.
3. Rhythmic shaking.
4. Athetoid movements.
Correct Answer: 3
Rationale 1: Fasciculations are muscle twitches.
Rationale 2: Chores refer to controllable jerking movements as are associated with Huntington’s disease.
Rationale 3: Rhythmic shaking of the hands is a manifestations associated with Parkinson’s disease.
Rationale 4: Athetoid movements are repetitive and slow and are seen with cerebral palsy.
Global Rationale: The tremors noted with Parkinson’s disease produce rhythmic shaking of the hands. Fasciculations are muscle twitches; chorea is the uncontrollable jerking associated with Huntington’s disease; athetoid movements are repetitive and slow and are seen with cerebral palsy.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 26.1: Describe the anatomy and physiology of the neurologic system.
MNL Learning Outcome: 11.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 791