Exam Review

Benign prostatic hypertrophy

(BPH) Urinary retention in males

S2 heart sound

- Closure of the semilunar valves - Signifies diastole

Terms to describe skin color

- Cyanosis (blue) - Jaundice (yellow) - Pallor (white)

Venous pooling

- Deoxygenated blood pools - Causes the skin to appear leathery

S3 heart sound

- Early diastolic sound - Created by the vibrations caused by blood flow into the ventricles

Palpating apical pulse

- Find sternal notch -

Cause of varicose veins

- Increased intravenous pressure - Incompetent valves

OLDCART

- Onset, location, duration, characteristics, aggravating factors, relieving factors, treatment - Used to collect an HPI (history of present illness) about pain

Arteriole insufficiency

- Oxygenated blood from heart to periphery - Blockage occurs

Assessments used to describe patient's hydration status

- Skin turgor/elasticity - Moistness/dryness of skin

Functional assessment

- Smoking habits - Drug and alcohol use - Nutrition - Caffeine intake - Sleep patterns Etc.

Tests for lung consolidation

- Tactile fremitus - Bronchophony - Egophony - Whispered pectoriliquy

Routes of temperature measurement

- Temporal - Tympanic - Oral - Axillary - Rectal

Before assessing the client's carotid arteries for pulsations, the nurse would raise the head of the client's bed to how many degrees of elevation for proper positioning?

45 degrees

Cranial nerves functioning as both the motor and sensory systems

5, 7, 9, 10

ABCDEs of skin cancer

Asymmetry, border, color, diameter, evolution

S1 heart sound

Closure of the AV valves

Symptoms of a urinary tract infection

Complaints of increased urinary frequency and dysuria

Doppler

Device used to assess the presence of unpalpable pulses

1:2

Expected anterior-posterior transverse diameter of the thorax

How to test cranial nerves 3, 4, and 6

Eye movement

Pattern for auscultating the lungs

From side to side

How to test cranial nerve 8

Hearing and balance

Deviated trachea

Indicates uneven thoracic pressure

The ___ kidney is higher than the ___ kidney.

Left; right

How to assess the heart rate if the pulse is irregular

Listen to the apical pulse for 60 seconds

Where to place the stethoscope to assess the apex of the lungs

Near the right clavicle

Signs of peripheral arterial disease in the lower extremities

Pale wound bed with well-defined edges

How to test cerebellar function

Performance of rapid alternating movements

How to test cranial nerve 11

Shoulder shrugs and head turns

Cardinal rule for auscultation

Stethoscope to skin

Cheyne-Stokes

Type of breathing exhibiting an increase in depth and rate, followed by periods of apnea

During a respiratory assessment, the nurse would elicit fremitus by doing which of the following during an examination? a. Placing the hands over anterior and posterior lung fields, asking the patient to say "99" b. Asking the client to say "99" while listening to the lungs with a stethoscope c. Palpating the anterior and posterior chest and costal margins d. Percussing over the anterior and posterior chest.

a

The nurse is performing a respiratory assessment on a client who is presenting with an underlying obstructive pulmonary disease. What is the most important question for the nurse to ask the client during the interview to provide information about contributing risk factors? a. "Have you ever smoked tobacco products?" b. "Have you had your immunizations?" c. "Do you experience dyspnea?" d. "Are you currently using over-the-counter medication for your cough?"

a

In the client with mitral regurgitation, the nurse would confirm the presence of a murmur at which location on the anterior chest? a. Apex b. Aortic area c. Pulmonic area d. 2nd intercostal space

a (Aortic area = 2nd intercostal space)

During inspection of the carotid arteries, the nurse assesses a bounding pulse. The nurse should evaluate the client for which additional finding? a. Fever b. Bruits c. Chest pain d. Cyanosis

a (Bounding pulses may signify fever, which increases the body's need for oxygen and blood flow. Bruits are turbulent blood flow and usually indicate blockage. Chest pain is not associated with bounding pulse. Cyanosis is associated with decreased oxygenation.)

When performing respiratory assessment of an adult client, the nurse notes hyperresonance on percussion. The nurse would conclude that this is due to which of the following? a. Pulmonary disease b. Scoliosis c. A mass d. Pain

a (Hyperresonance on percussion may be caused by COPD or emphysema. Scoliosis may produce respiratory difficulty in individuals. A mass or consolidation in the lungs may produce adventitious sounds, dullness, and bronchial or bronchovesicular sounds. Pain does not produce hyperresonance.)

A client who has been in a motor vehicle accident has decreased lung sounds on the right side of the chest, decreased fremitus, tracheal deviation to the left, and pain and hyperresonance on the left. The nurse should prepare to implement which intervention? a. Prepare chest tube drainage setup b. Administer a pulmonary bronchodilator c. Prepare client for emergency tracheostomy d. Administer low flow oxygen via nasal cannula

a (The chest tube drainage system must be set up as the client is experiencing a medical emergency caused by pneumothorax. The pneumothorax is causing the decreased breath sounds on the affected side and tracheal deviation to the opposite side. The client is having difficulty breathing but does not have a constricted airway so a bronchodilator will not help. A tracheostomy will not help unless the client requires an airway and an endotracheal tube cannot be placed. The client will need high-dose oxygen, not low flow.)

The nurse performing a cardiovascular assessment observes splinter hemorrhages. The nurse should evaluate this client for which of the following? a. Endocarditis b. An aneurysm c. Bruits d. Poor circulation

a (The client experiencing endocarditis may have splinter hemorrhages of the fingernails. Aneurysms would be assessed by inspecting for pulsations or auscultating for bruits. A bruit is assessed by listening over an artery for turbulent blood flow. Poor circulation would be evaluated by inspecting for hair distribution changes on the lower extremities as well as skin color changes or palpating for pulses.)

The nurse is caring for a client who has curvature of the thoracic and lumbar spine. The nurse should develop a plan of care based on which priority risk diagnosis? a. Impaired gas exchange b. Impaired comfort c. Disturbed body image d. Ineffective social relationships

a (The client with a curvature of the spine may experience difficulty breathing and exchanging gases due to to decreased lung volume.)

When evaluating a client's circulation, the nurse should include which assessments? Select all that apply. a. Palpation of pulses b. Skin temperature of bilateral extremities c. Skin color d. Skin dryness e. Hair on the legs and feet

a, b, c, e (Skin dryness is an indicator of general skin condition.)

When obtaining a cardiovascular health history, the nurse should ask the client which questions? Select all that apply. a. "Are you able to perform your activities of daily living?" b. "Do you have musculoskeletal aches?" c. "Have you had any weight changes?" d. "Have you been treated for cardiovascular disease?" e. "Do you know your cholesterol and triglyceride levels?"

a, c, d, e

When auscultating the apical pulse the nurse should assess for which characteristics? Select all that apply. a. Rate b. Intensity c. Temperature d. Regularity e. Rhythm

a, d, e (Intensity is a term used to describe the strength of a murmur. If there is a pulse, the extremity should be warm to the touch.)

The client is admitted to the hospital. During the assessment, the nurse notes dyspnea, decreased fremitus, dullness over the right lung, and decreased breath sounds on the right with a pleural friction rub. The nurse would prepare the client for diagnostic tests to evaluate for which problem? a. Pneumothorax b. Pleural effusion c. Congestive heart failure d. Pneumonia

b

The nurse caring for a client experiencing chest discomfort should obtain which assessment data from the client? a. Presence of a fever b. Description of the pain and location c. Recent weight gain d. Whether the client smokes

b

When palpating the carotid arteries it is essential that the nurse do which of the following? a. Palpate the carotids while the client is supine b. Avoid palpating the carotids simultaneously c. Determine if there is a heave d. Palpate for an enlarged heart

b

When performing a dietary history on a client with a cardiovascular history, the nurse should obtain information related to which items? a. Dairy consumption b. Sodium intake c. Whole grain intake d. Vitamin supplements

b

The nurse assessing a client who has a history of hypertension would assess the client for pulsations by palpating which cardiac landmark? a. 5th intercostal space, midclavicular line b. 2nd intercostal space, right sternal border c. Pulmonic area d. Tricuspid area

b (A murmur at the 5th intercostal space, midclavicular line (apical area) may be the result of mitral regurgitation. A murmur at the pulmonic area may be the result of pulmonary stenosis. A murmur at the tricuspid area may be the result of tricuspid stenosis.)

The nurse is caring for an older adult client who states, "It is more difficult for me to breathe when I clean the house." To what would the nurse relate this clinical manifestation? a. Deconditioning of the cardiac system b. A normal age-related change c. A respiratory infection d. Environmental exposure

b (As a person ages, there is a loss of elasticity in the lung that makes it more difficult to take deep breaths. As long as the older adult stays active, there should be little conditioning. A respiratory infection causes fever, malaise, greenish-yellow productive cough. Environmental exposure may cause constrictive symptoms like wheezing.)

The nurse is performing a cardiovascular assessment. To evaluate the client for pulmonary edema, the nurse would assess the client for which manifestation? a. Edema in the lower extremities b. Shortness of breath c. A thrill d. Splinter hemorrhages

b (Edema in the lower extremities might indicate lymphedema or heart failure. A thrill is palpated and indicates turbulent blood flow. Splinter hemorrhages are red lines in the nails due to endocarditis.)

The nurse is performing a respiratory assessment on an older adult client who has a history of dizziness and is at risk for falls. Which aspect of the respiratory assessment is most important for the nurse to complete in determining contributing factors that could enhance risk for falls? a. Position of comfort to detect orthopnea b. Respiratory rate to detect hyperventilation c. Apical-radial deficits to determine pulse deficits d. Lung sounds to assess for bibasilar crackles

b (Hyperventilation could worsen the client's dizziness and increase the risk for falls.)

A client who has been diagnosed with a myocardial infarction presents with a complaint of "awakening in the middle of the night with a feeling of not being able to breathe." What is the appropriate action for the nurse to take? a. Have the client keep a log of number and length of awakenings with a heart and respiratory rate to provide data for evaluation b. Instruct the client to sleep in semi-Fowler's position because of paroxysmal nocturnal dyspnea c. Instruct the client to cough and deep breathe as client is experiencing COPD d. Encourage the client to use a CPAP machine for sleep apnea

b (Paroxysmal noctural dyspnea (PND) is the experience of waking up at night with dyspnea.)

When assessing a client who reports a cough, it is essential that the nurse evaluate the cough by asking which of the following questions? Select all that apply. a. "How long do you think you will be able to tolerate this cough?" b. "How long have you been coughing?" c. "Can you describe your cough?" d. "Are you coughing up mucus?" e. "Do you have pain when you cough?"

b, c, d, e

In preparing to perform a cardiovascular assessment, the nurse should initially place the client in what position? a. Supine b. Lithotomy c. Sitting upright d. Prone

c

The nurse is assessing a client who has a low-pitched murmur. What is the most appropriate way for the nurse to position the client to auscultate this murmur? a. Supine using the bell of the stethoscope b. Supine using the diaphragm of the stethoscope c. On the left lateral side using the bell of the stethoscope d. On the left lateral side using the diaphragm of the stethoscope

c

The nurse is teaching a client with allergies about work-related allergens. To prevent respiratory distress, the nurse should instruct the client to avoid which of the following? a. Eating lunch with co-workers who are eating foods to which the client is allergic b. Having allergy testing to prevent anaphylaxis c. Contact with people who are smoking d. Exercise to decrease dyspnea

c

The nurse is assessing a client whose respiratory rate is 20 breaths per minute with symmetrical chest movement. The nurse will interpret this to be a normal finding in which client? a. Infant b. Pregnant female in the third trimester c. Middle-aged client d. An older adult client with lung disease

c (An infant would have a more rapid respiratory rate, such as 30-40 breaths per minute. A pregnant female may experience tachypnea and dyspnea due to pressure on the diaphragm. An older adult client may have tachypnea due to loss of elasticity or lung disease.)

During a cardiovascular assessment, the nurse finds a bluish tinge on the client's lips, fingers, and toes. What is the appropriate documentation for this finding?y a. Central cyanosis b. Peripheral cyanosis c. Central and peripheral cyanosis d. Cyanosis

c (Central cyanosis is cyanosis of the lips and peripheral cyanosis is cyanosis of the hands and/or feet.)

After percussing the client's thorax and hearing dullness in the right middle lobe, the nurse would conclude that this assessment finding is consistent with which health problem? a. COPD b. Pneumothorax c. Tumor d. Bronchitis

c (During percussion for a client experiencing COPD or pneumothorax, the nurse would elicit hyperresonance. Resonance would be elicited in a bronchitis client as well. Dullness would indicate a solid area like a tumor.)

The nurse is performing a cardiovascular assessment and notes creases in the client's earlobes. Based on this finding the nurse would conclude that the client may be experiencing which condition? a. Endocarditis b. Pericarditis c. Coronary artery disease d. Fluid overload

c (Endocarditis manifests with fever, fatigue, and murmur. Pericarditis manifests with fatigue, shortness of breath, and pericardial friction rub. Fluid overload manifests as shortness of breath, edema, and increased jugular vein distention.)

The nurse is caring for a client who is coughing up greenish-yellow mucus. Based on this clinical manifestation, the nurse would conclude that the client is experiencing which respiratory condition? a. Tuberculosis b. Hemoptysis c. Lung infection d. Pleural effusion

c (Tuberculosis would produce a cough with rust-colored sputum. Hemoptysis is blood-tinged sputum. Pleural effusion does not cause a productive cough.)

The nurse is performing a respiratory assessment on a client and finds unequal chest excursion. The nurse would conclude that this may be caused by which of the following factors? a. Client's physical stature b. COPD c. Collapse or obstruction of part of the lung d. Diaphragmatic breathing

c (When part of the lung is collapsed, the client experiences unequal chest excursion.)

What approach would the nurse use to elicit the cooperation of a school-age child during a cardiovascular assessment? a. Explain procedure to the child b. Explain procedure to the parents c. Permit the child to listen to his or her parent's chest with stethoscope d. Sedate the child

c (This measure would help reduce the child's fear and make them familiar with the procedure and equipment.)

The client has a history of COPD. The nurse should expect to document which clinical manifestations following physical examination? Select all that apply? a. Increased tactile fremitus b. Asymmetrical excursion c. Decreased bilateral excursion d. Fine crackles e. A transverse to anteroposterior diameter of 1:1

c, e (The client with a history of COPD will have a barrel-chest appearance in which the AP transverse diameter is 1:1 instead of 1:2. The nurse should expect decreased excursion that is symmetrical. The client will not have crackles but will demonstrate wheezing. Because of the increased diameter and decreased air velocity, the client will have decreased fremitus.)

The client has a history of aortic stenosis and an S3 murmur. What action would the nurse take to auscultate this murmur? a. Listen at the pulmonic area. b. Use the diaphragm of the stethoscope c. Listen at the 2nd intercostal space d. Use the bell of the stethoscope

d

The nurse is assessing the client and notes shallow breathing with periods of apnea. When participating in interdisciplinary care rounds, the nurse should report that the client is experiencing which of the following? a. Bradypnea b. Cheyne-Stokes respirations c. Hyperventilation d. Biot's breathing

d (Bradypnea is slow breathing. Cheyne-Stokes involves deep breathing with periods of apnea. Hyperventilation involves rapid deep respirations.)

The nurse has auscultated the client's lungs and hears bubbling sounds bilaterally in the lower lung fields. The nurse would document which finding in the client's medical record? a. Bilateral bronchi at the bases b. Expiratory wheezing at the bases c. Inspiratory wheezing at the bases d. Bilateral crackles at the bases

d (Fluid-filled space produces crackling, bubbling sounds, which are known as crackles. In the lung fields, fluid always pools to the center of gravity. Wheezes are high-pitched musical sounds usually found in the upper airways and are produced by constriction of the airways. Rhonchi are sonorous sounds that may clear with coughing.)

During a cardiovascular assessment, the nurse notes that the client has a heart rhythm with a pause after each beat and a skip every third beat. What is the appropriate interpretation of this finding? a. Asystole b. Normal c. Regular d. Regularly irregular

d (Normal rhythm is when every beat occurs as expected. Regular rhythm is when every beat comes as expected. Regularly irregular is a rhythm that occurs in a patterned regularity but abnormal heart rhythm.)

The client is admitted to the hospital unit reporting inability to sleep because of shortness of breath. The nurse should take which preferred action? a. Reassure the client that this will resolve shortly b. Evaluate the client for history of asthma c. Position the client in right lateral Sim's position d. Have the client sleep on 2 pillows

d (The client is experiencing orthopnea, or difficulty breathing when lying down. A more upright position using pillows should decrease the feeling of not being able to breathe.)

In what order would the nurse complete the following components of a respiratory assessment on an assigned client? a. Percuss the anterior thorax b. Palpate the anterior thorax c. Position the client d. Explain the procedure to client e. Auscultate the anterior thorax

d, c, b, a, e