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Home Health Aide Certification (HHA) EXAM COMPLETE
5 00 QUESTIONS AND VERIFIED SOLUTIONS LATEST
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HHA (Home Health Aide Certification) EXAM QUESTION: A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? A. Snellen Chart B. Sugar C. Cotton Wisps D. Coffee - ANSWER-C. Cotton Wisps Rationale: The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth. Incorrect answer: A. The nurse should use the Snellen chart to test the function of the optic nerve (CN I|). B. The nurse should use sugar to test the function of the facial nerve (CN VII)
D. The nurse should use coffee to test the function of the olfactory nerve (CN I). QUESTION: A bruit of the temporal artery is suspected when the nurse hears A. a soft blowing sound B. a clicking sound C. a should like hair rustling D. a vibration - ANSWER-A. a soft blowing sound Rationale: A bruit can be heard through the bell of the stethoscope as a soft blowing sound and is indicative of narrowing of the vessel. A click is often heard when there is an artificial heart valve present. Vibrations usually are palpated, not heard. Some people compare respiratory crackles with hair rubbing together. QUESTION: A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. "Turn your head to the side against my hand." B. "Tilt your head slightly forward." C."Keep your head straight and look ahead of you." D. "Tilt your head back and swallow." - ANSWER-D. "Tilt your head back and swallow." A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
C. displacement due to ascites. D. enlargement of the liver. - ANSWER-B. a normal finding. Rationale: The normal liver span - the distance between the lower and upper borders of the liver - should be approximately 5 to 10 cm (2-4 inches). Liver enlargement below the costal margin suggests displacement downward as a result of respiratory disease, and displacement upward suggests ascites or a mass. QUESTION: The nurse palpates the abdominal aorta of an adult client and finds that it measures approximately 6 cm in diameter. The next step for the nurse to take is A. To palpate lightly to just under the xiphoid process B. Discontinue palpation and document findings C. Auscultate for bruits D. To continue to apply deep palpation inferiorly to assess accurate measurement - ANSWER-B. Discontinue palpation and document findings Rationale: The aorta is palpable in the upper abdomen to the left of midline below the xiphoid process and the average adult aorta is 3 cm wide. A widened aorta may indicate aneurysm and should not be palpated to avoid rupture QUESTION: The nurse is auscultating a client's abdomen for bowel sounds and no sounds have been detected for at least two minutes. The nurse should
A. Document this finding as normal and move on to the next step of the physical assessment B. Document bowel sounds absent and identify the appropriate location C. Call the physician D. Listen for at least three more minutes - ANSWER-D. Listen for at least three more minutes Rationale: It may be difficult for the nurse to hear bowel sounds in some clients and all four quadrants should be auscultated for a total of at least five minutes before documenting absent bowel sounds. QUESTION: The nurse is percussing over the client's bladder and notes a dull tone. The nurse understands this to represent A. Air trapped in the intestines B. A full bladder C. An empty bladder D. Percussion over one of the kidneys - ANSWER-B. A full bladder QUESTION: A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: A. Sexual history, because discussing it first will build rapport. B. Menstrual history, because it is generally nonthreatening.
C. Notify the physician of the findings. D. Document the findings as normal. - ANSWER-D. Document the findings as normal. Rationale: According to Tanner's Maturation Stages in the male, the findings in this situation are appropriate for the adult male client. no further subjective information is required by the nurse and the physician does not need notification. QUESTION: A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A. Palmar Surface B. Dorsal surface C. Base of the fingers D. Fingertips - ANSWER-B. Dorsal surface Rationale: The dorsal surface of the hand is the most sensitive to temperature. QUESTION: Palpation of the adult client's neck reveals nonpalpable lymph nodes. This is A. Reason for referral to an ear, nose, and throat specialist B. A normal finding in adults
C. Probably caused by an infection D. Cause to inspect for further malformations - ANSWER-B. A normal finding in adults Rationale: Lymph nodes of the head and neck are non-palpable in adults, If an infection were present, the lymph nodes of the surrounding area would be tender and possibly enlarged. The lymph chains of the adult neck should not be able to be palpated and this could be a normal finding in the physical examination. Rationale: To examine the thyroid gland, the nurse should instruct the client to extend her head backward and to swallow. The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland. Incorrect: A. To evaluate the strength of the neck muscles, the nurse should place a hand on the side of the client's head and ask her to turn her head against the resistance from the hand. B. To palpate the supraclavicular lymph nodes, the nurse should instruct the client to tilt her head forward and relax her shoulders C. To palpate the trachea for any deviation to the side, the nurse should instruct the client to keep her head in an erect, neutral position.
QUESTION: During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A. Accommodation test B. Corneal light reflex C. Symmetry of palpebral fissures D. Confrontation test - ANSWER-B. Corneal light reflex Rationale: The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes wil not align when the client focuses. Incorrect Answers: A. The test for accommodation determines whether the client's pupils constrict as they focus on an object the examiner brings closer to the eyes. C. The palpebral fissure is the space between the eyelids, which is unequal in clients who have ptosis (i.e. drooping of one or both of the evelids). D. A confrontation test compares the visual fields of the client with that of the examiner.
QUESTION: A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? A. Eye examination every 2 years B. Annual Papanicolaou (Pap) testing C. Mammogram every 2 years D. Annual colonoscopy - ANSWER-A. Eye examination every 2 years Rationale: This is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward. Incorrect Answers: B. Women ages 30 to 65 years should have a Pap test every 3 years. C. Women ages 45 years and older should have an annual mammogram. At age 55, clients may decide to change this schedule to every 2 years or continue with annual mammograms. D. The client should have a colonoscopy every 10 years. If the client has risk factors for colorectal cancer, testing should occur more often and with other evaluations. QUESTION: A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? A. Reading the newspaper
C. Pain during palpation D. Firm pressure - ANSWER-D. Firm pressure Rationale: The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection QUESTION: A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? A. Ensure the client receives a soft diet. B. Provide an obstacle-free path for ambulation. C. Initiate seizure precautions. D. Instruct the client to use lukewarm water when showering. - ANSWER-B. Provide an obstacle-free path for ambulation. Rationale: Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve Il is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation. Incorrect Answers: A. Clients who have an impairment of cranial nerve IX require this precaution because they are likely to have difficulty swallowing.
C. Seizures are the result of various neurological and metabolic imbalances, such as hypocalcemia and hypomagnesemia; however, none of the cranial nerves affects seizure activity. D. Clients who cannot accurately sense temperature extremes (e.g. those with peripheral neuropathy) should avoid hot-water showers. Cranial nerve II does not affect the client's ability to sense temperature extremes QUESTION: A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Face the client when speaking B. Exaggerate lip movements C. Speak directly into the client's impaired ear D. Speak loudly - ANSWER-A. Face the client when speaking Rationale: The nurse should directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing-impaired combine lip reading with their residual hearing when communicating. QUESTION: A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Irrigate the ear with warm water
Rationale: A client who has hearing aids can undergo MRI because the hearing aids can be removed. The powerful magnetic field of the MRI system could damage the hearing aids, so they should be removed prior to the client undergoing MRI. Incorrect Answers: A. A coronary artery stent is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could pull on the metal stent and dislodge it. B. An aneurysm clip is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could pull on the metal clip and dislodge it. D. An automated internal defibrillator is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could damage the defibrillator and cause it to malfunction. QUESTION: A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is greater than bone conduction in the left ear. B. Sound is lateralizing to the right ear C. Sound is lateralizing to the left ear. D. Air conduction is less than bone conduction in the left ear. - ANSWER-D. Air conduction is less than bone conduction in the left ear.
Rationale: This finding indicates conductive hearing loss of the left ear. Incorrect Answers: A. This finding does not indicate hearing loss of any type. B, C. These are possible results of the Weber test, not the Rinne test. QUESTION: A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? A. Provide a lengthy interview process to allow adequate time to answer questions B. Sit beside the client during the interview C. Make sure lighting in the room is soft D. Make sure the device is functioning - ANSWER-D. Make sure the device is functioning Rationale: The nurse should ensure that all of the client's assistive devices are working before beginning the interview process. Incorrect Answers: A. The interview process should be brief so it does not tire the client. The nurse can gather additional data at a later time.
QUESTION: A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? A. Use a tongue blade to provoke a gag reflex B. Have the client open his mouth and say, "aah" C. Ask the client to identify the scent of coffee D. Have the client smile and raise his eyebrows - ANSWER-B. Have the client open his mouth and say, "aah" Rationale: The vagus or X nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth and say, "aah." The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness. Incorrect Answers: A. Using a tongue blade to provoke a gag reflex assesses the function of cranial nerve IX, the glossopharyngeal nerve. C. Asking the client to identify the scent of coffee assesses the function of cranial nerve I, the olfactory nerve. D. Having the client smile and raise his eyebrows assesses the function of cranial nerve VII, the facial nerve.
QUESTION: A nurse is preparing to assess the function of the client's Olfactory nerve (cranial nerve I). Which of the following items should the nurse gather for the test? A. Cotton Wisps B. Sugar C. Snellen Chart D. Coffee - ANSWER-D. Coffee Rationale: The Olfactory nerve (Cranial Nerve I) is a sensory nerve. To assess its sensory function, the nurse uses a familiar non-noxious odor such as coffee or citrus to evaluate the smelling test. The patient is instructed to cover his/her eye and guess. Incorrect Answers: A. Cotton Wisps is used for CN V B. The nurse should use sugar to test the function of the facial nerve (CN VII) C. The nurse should use the Snellen chart to test the function of the optic nerve (CN I|). QUESTION: A nurse is teaching a client who wants to stop smoking by using nicotine gum. The nurse should inform the client that which of the following adverse effects can occur from using nicotine gum? A. Hiccups B. Teary Eyes
