Question

. A patients states, whenever I open my mouth real wide , I hear this popping sensation in my ears how would the nurse further assess. Select all that apply

A. Place the stethoscope over the temporomandibular joint and listen for bruits.

B. Ask if the grinds their teeth at night or chews gum frequently.

C. Place one hand on the client’s forehead and the other on their jaw , and ask the client to try to open their mouth .

D. place a finger over each of the client’s temporomandibular joints , and ask the client to open and close their mouth.

E. Examine the teeth for signs of decay

Nurses collect subjective and objective data when performing client assessments, what is an example of objective data,

A. A client receiving chemotherapy complaints of nausea

B. A client states that they are feeling very anxious about their tests

C. A client with an inner ear infection complaint of dizziness

D. The skin of a client who has liver failure has a yellowish tint

On inspection of a client’s leg. The nurse notes the skin is shiny and tight without hair growth what

A. Increased circumference in the thighs bilaterally

B. A round ulcer on the medial malleolus

C. Pitting edema or both feet or legs

D. Warm swollen legs with 2+ pedal pulses

Answer 1

1.

A patient states, whenever I open my mouth real wide, I hear this popping sensation in my ears.

For further asses place a finger over each of the client’s temporomandibular joints, and ask the client to open and close their mouth because the popping sound is caused due to the dysfunction of temporomandibular joints.

Answer - D. place a finger over each of the client’s temporomandibular joints, and ask the client to open and close their mouth.

2.

Nurses collect subjective and objective data when performing client assessments, an example of objective data is the skin of a client who has liver failure has a yellowish tint.

Objective data means the data collected from observation. It is known as signs.

Answer - D. The skin of a client who has liver failure has a yellowish tint

3.

On inspection of a client’s leg. The nurse notes the skin is shiny and tight without hair growth it indicates Pitting edema or both feet or legs.

Pitting edema is characterized by shiny swelling which is caused by fluid deposition inside the skin.

Answer - C. Pitting edema or both feet or legs