AO3320-600 Exam 3

Question 2

AO3320-600 Exam 3. The nurse is providing care for a client with dark skin tone who was admitted with cellulitis in the right lower extremity. What is the best technique for identifying erythema in this client?

• Pinch the skin on the right lower extremity for turgor.
• Assess the oral mucosa for redness and induration.
• Inspect the skin for rash.
• Palpate the skin for swelling and temperature. ✅

Question 3

While assessing the client’s skin, the nurse notes a mole on the client’s shoulder. What finding is most concerning for the presence of melanoma?

• Borders are even
• Color is solid, dark brown
• Diameter is 1.5 mm
• Elevated lesion ✅

Question 4

A 66-year-old client has come to the clinic with complaints of recent weight gain, constipation, thin, brittle hair and weakness. They state, “I can never seem to get warm, no matter what the thermostat is set at.” What other assessment would the nurse perform?

• Perform range of motion of the neck to assess for stiffness.
• Palpate the throat for a goiter. ✅
• Inspect the eyes for periorbital edema.
• Auscultate the thyroid to assess for a bruit.

Question 5

A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client’s temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

• “I’m going to place my fingers in front of your ear, and I want you to open your mouth as wide as possible.”
• “I want you to move your jaw from side to side and tell me if there is any pain with the movement.”
• “Push out and pull in your lower jaw and let me know if you experience popping or grating.”
• “I am going to place my hand on your cheek, and I want you to turn your head against resistance.” ✅

Question 6

A client comes in with complaints of a headache. The client states, “I always wake up with a headache in the morning, but it gets better in a couple hours. I notice it always gets worse if I cough or sneeze.” What action by the nurse is most appropriate?

• Explain that migraine headaches can last a long time.
• Palpate the occipital lymph nodes.
• Administer morphine 10mg IV every 4 hours for the pain.
• Assess the client’s neurological status. ✅

Question 7

During the health history a client describes recent episodes of intermittent facial pain lasting several minutes. The vital signs are 98.6° F orally, pulse 86, respirations 20, blood pressure 142/88 and O2 saturation of 96%. The nurse should recognize that this complaint is suggestive of what health problem?

• Meningitis
• Trigeminal neuralgia ✅
• Migraine headache
• Temporomandibular joint dysfunction

Question 8

A client is admitted with high fever of 102° F orally and an elevated WBC of 15,000. They state they have had a sinus infection and a sore throat for over 24 hours. A nurse is preparing to palpate the client’s lymph nodes. At what anatomic location should the nurse position his or her hands to assess the submental lymph node?

• At the angle of the client’s jaw
• Behind the tip of the client’s chin ✅
• On the area behind the client’s ears
• At the base of the client’s skull

Question 9

While inspecting the tympanic membrane the nurse notes a pearly gray and shiny appearance. What would this finding indicate?

• Serous otitis media
• Scarring from previous infections
• Acute otitis media
• Intact tympanic membrane ✅

Question 10

A nurse is planning a personal safety educational session for those who work in a manufacturing plant. Which of the following would be an important risk prevention measure to include regarding hearing?

• “Ototoxic medications can damage hearing and should be avoided.”
• “It is important to have general hearing screening tests every year.”
• “Hearing loss can be caused by long or repeated sounds above 85 decibels.” ✅
• “Wear hearing protectors when in loud environments.” AO3320-600 Exam 3

Question 11

A nurse is completing the Romberg’s test on a patient. Which is the correct technique for conducting this?

• Have the client stand with feet together, arms at the sides. Begin with eyes open then with eyes closed. Try to maintain position for 20 seconds. ✅
• Instruct the client to walk across the room on his heels and to return walking on his toes.
• Ask the client to touch the thumb of one hand to each finger on that same hand and then repeat using the other hand.
• Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.

Question 12

A health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients on how to clean their ears, what action should the nurse recommend?

• “You should gently irrigate with normal saline.”
• “If you note fullness in your ear, try to remove the impaction with a cotton swab.”
• “Ear candles are a good way to help remove impacted cerumen.”
• “Wash the pinna of your ear with a warm, moist washcloth.” ✅

Question 13

A nurse is caring for a client who has presbycusis. Which of the following actions should the nurse take?

• Prepare to remove the blockage in the ear.
• Speak directly to the client, a little more slowly, in a normal, clear voice. ✅
• Raise your voice and speak loudly and into the client’s good ear.
• Sit by the client’s side and speak very slowly.

Question 14

The nurse has completed the assessment of the client’s ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?

• Document this normal finding ✅
• Assess for further signs of infection
• Set up a teaching session regarding ear hygiene
• Make a note on the chart so the clinician can order ear drops

Question 15

During an inspection of a client’s tonsils with a penlight and tongue depressor, the nurse notes that the tonsils contact the client’s uvula. The patient states they have had a sore throat and have been using lidocaine spray as directed by the provider. What would be the most accurate documentation of this finding?

• 4+
• 2+
• 3+ ✅
• 1+

Question 16

The nurse is reviewing a client’s electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow up?

• Thrush
• Leukoplakia ✅
• Canker sore
• Gingivitis

Question 17

The client reports a decrease sense of smell for the past week. Which condition would the nurses assess for?

• Nasal polyps ✅
• Bell palsy
• Leukoplakia
• Lesion of cranial nerve V

Question 18

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? AO3320-600 Exam 3

• Prolonged tonsillar enlargement
• Incomplete immunization record
• History of epistaxis nosebleeds
• History of allergies ✅

Question 19

While examining a client’s mouth the nurse notes the presence of fasciculations, fine tremors of the client’s tongue. How should the nurse best respond to the assessment finding?

• Assess the client’s cranial nerve function ✅
• Prepare the client for a thyroid screening
• Review the client’s medication regimen
• Have the client provide a 24-hr diet recall

Question 20

The nurse assesses thick, white plaques on a client’s tongue and hard palate. Which of the following nursing actions should the nurse do next?

• Facilitate blood testing for human immunodeficiency virus (HIV)
• Assess the client’s laboratory values for zinc deficiency
• Refer the client to a primary care provider for prescriptive medication ✅
• Assess the client for signs of jaundice

Question 21

A nurse is integrating health promotion education into the assessment of a client’s mouth, nose and throat. What interview question is most likely to identify a risk factor for oral cancer?

• Do you have any difficulty chewing or swallowing?
• How often do you usually go to the dentist in a year?
• Have you been prescribed immunosuppressive therapy?
• Do you have a history of chronic rhinitis?

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Question 22

The nurse has assessed the client’s vital signs and cardiac system. They move on to assess the respiratory assessment. See the findings in the table below:

Category	Findings
Vital Signs	Blood pressure: 118/70; Heart rate: 89 beats per minute; Respiratory rate: 20 breaths per minute; Temperature: 98.0°F; Oxygen saturation: 93% on room air
Cardiac Assessment	Regular rhythm with s1 loudest at the apex and s2 loudest at the base of the heart. S3 identified. No murmurs heard.
Respiratory Assessment	Breathing Appears unlabored. Equal chest expansion, crackles heard in lower lobes anterior and posteriorly.

Which of the following should the nurse do next?

• Assess the peripheral vascular system.
• Apply oxygen via nasal cannula and recheck the oxygen saturations in five minutes.
• Notify the provider of the findings.
• Have the client cough and auscultate all lung fields again.

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Question 23

The nurse has begun the objective assessment of a client’s heart and neck vessels and is assessing the client’s jugular veins. What finding would the nurse consider to be expected in a healthy client?

• The jugular venous pulse is visible when the client lies supine.
• The jugular veins are fully distended when the client is in a high Fowler position.
• The jugular venous pulse is not visible when the client is sitting upright.
• The jugular veins are distended when the client sits at a 45-degree angle.

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Question 24

The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client’s peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

• Radial
• Femoral
• Ulnar
• Brachial

Question 31

The nurse has placed her hands behind the client’s head and flexed his neck forward as far as he can tolerate. During the test the client experiences leg pain and bends his knees. In addition, he complains of neck pain. This assessment finding is suggestive of what health problem?

• Trigeminal neuralgia
• Bell’s palsy
• Ischemic stroke
• Meningitis