HEENT, GI, GU

•  

  PERRLA refers to:

• Motor Function

• Order of Assessment

• Level of Consciousness

• Pupillary Response

What all will the nurse assess when assessing the ears ?

Ear: external structure, alignment, position, drainage, tenderness 

• External structure

• Alignment & Position

• Hearing

• Drainage

• Tenderness

What is the term for involuntary shaking movement of the eyeball in a horizontal, vertical, rotary or mixed direction ?

• Nystagmus

• Myopia

• Hyperopia

• Starbismus

The nurse is performing an eye assessment on a client. Which finding confirms normal accommodation during visual assessment?

• Both pupils constrict when a light is shined at one eye.

• The client blinks in response to a threatening movement.

• Both pupils constrict when focusing on an object being moved in toward the nose.

• The client is able to hold an upward gaze without moving the head for 15 seconds.

Where is the submental lymph node located ?

• 2

• 5

• 1

• 8

• 6

What vascular sound is the nurse assessing ?

• Aortic

• Renal

• Iliac

• Femoral

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ______ profile.

• 
  
  Flat
  
  

• Convex

• Bulging

• Concave

In what order would you perform physical examination of the abdomen ?

• Inspect, Auscultate, Palpate, Percuss

• Inspection, palpation, percussion, auscultation

• Inspect, Percuss, Auscultate, Palpate

• Auscultate, Inspect, Palpate, Percuss

Before a nurse can document absent bowel sounds they must listen to each quadrant for how long ?

• One minute

• Three minutes

• Five Minutes

• Two Minutes

When assessing bowels which quadrant do you start in ?

• RLQ

• LLQ

• RUQ

• LUQ