Page 411 - Saunders Comprehensive Review For NCLEX-RN

option will direct you to this option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Health Assessment/Physical Exam: Ear, Nose, and Throat
Health Problem: Adult Health: Ear: Hearing Loss
Priority Concepts: Client Education; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), pp. 996-997.

94. Answer: 3

Rationale: A heart murmur is an abnormal heart sound and is described as a faint
or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub
sounds are normal and represent the S1 (first) heart sound and S2 (second) heart
sound, respectively. A pericardial friction rub is described as a scratchy, leathery
heart sound. A click is described as an abrupt, high-pitched snapping sound.
Test-Taking Strategy: Focus on the subject, characteristics of a murmur. Eliminate
option 1 because it describes normal heart sounds. Next recall that a murmur occurs
as a result of the manner in which the blood is flowing through the cardiac chambers
and valves. This will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Health Assessment/Physical Exam: Heart and Peripheral Vascular
Health Problem: Adult Health: Cardiovascular: Inflammatory and Structural
Heart Disorders
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman, Rebar (2018), p. 655.

95. Answer: 2

Rationale: Testing the 6 cardinal positions of gaze (diagnostic positions test) is
done to assess for muscle weakness in the eyes. The client is asked to hold the head
steady, and then to follow movement of an object through the positions of gaze. The
client should follow the object in a parallel manner with the 2 eyes. A Snellen eye
chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by
having the client close his or her eyes and then lightly touching areas of the face and
testing the corneal reflexes assess cranial nerve V (trigeminal).
Test-Taking Strategy: Focus on the subject, assessing for muscle weakness in the
eyes. Note the relationship between the words extraocular movements in the question
and positions of gaze in the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Health Assessment/Physical Exam: Ear, Nose, and Throat
Health Problem: N/A
Priority Concepts: Clinical Judgment; Sensory Perception

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