HA EXAM 3

When assessing the breasts, the client asks why is it important to lift their arms over their head. What is the basis for the nurse's response?

Adds tension to suspensory ligaments

When auscultating the carotids what are the 3 areas you need to auscultate over?

Angle of Jaw, Midcervical area, Base of neck

The nurse is preparing to assess a clients carotid arteries. Which technique should the nurse use during this assessment?

Ask the patient to hold their breath during auscultation

A hospitalized client has been in bed and not able to ambulate for 3 days. When assessing the right leg, the nurse observes edema and erythema. The calf is warm to touch and the client reports of pain in the calf area. What is the nurse's best action?

Assess for shortness of breath .

A nurse auscultates the heart of a client with hypertension for the past ten (10) years. With the client in the left lateral position, the nurse hears a heart sound that occurs just before S1. The nurse recognizes this sound as what pathological process?

Atrial contractions heard as vibrations against stiff walled ventricles

When auscultating the carotids what part of the stethoscope are you using?

Bell

Which type of discharge should a nurse consider normal with palpation of the nipples during a breast examination of a nonlactating female client?

Clear

The nurse notes that a client has a history of peripheral arterial disease. What should the nurse expect when assessing this client? Select all that apply.

Cold skin over the feet Toe wound that will not heal Pain in the calves when walking

Fibrous tissue that provides support for the glandular tissue of the breasts is termed

Cooper ligaments.

Which of the following are signs and symptoms of COPD

Digital Clubbing Easily Fatigued Chronic Cough Wheezing

During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing?

Effusion in the knee joint

A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply.

Flexion Extension Supination

When auscultating the carotids what are you listening for

For bruits

A nurse asks a client to say 99 as the nurse palpates the posterior thorax. the nurse is assessing which of the following?

Fremitus

A grandparent brings their 13-year-old grandchild for evaluation. They noticed last week when the child took off their shirt that their breastbone seemed collapsed.

Funnel chest (pectus excavatum)

While examining a client's breasts, a nurse notices milky discharge from the nipple. The client explains that they recently had a baby and are currently breastfeeding. The nurse understands that which type of tissue in the breast is responsible for allowing milk production?

Glandular

The nurse is assessing the range of motion (ROM) of a client's joints. What would the nurse use to assess flexion and extension of a joint if the client reports pain on examination?

Goniometer

What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs?

Have the client cough and then listen again.

A clients has a large pendulous breasts. What would be most appropriate to ensure better access while examining the client's breasts for reaction and dimpling

Have the client lean forward

The thoracic cavity contains which of the following organs? Select all that apply. Heart Lungs Most of the esophagus Stomach Pancreas

Heart Lungs Most of the esophagus

A client reports shortness of breath for the past few days. Examination reveals late inspiratory crackles in the lower third of the chest that were not present 1 week ago. What is the most likely explanation?

Heart failure

A client reports to the nurse that they experience fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process?

Heart failure

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Listen at each site for at least one complete respiratory cycle

A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?

Measure movement with a goniometer

Loss of bone density that occurs with greatest frequency in postmenopausal women is called?

Osteoporosis

A nurse is examining the breasts of a female client who has had a mastectomy. Which of the following should the nurse do?

Palpate the scar for redness, lesions, lumps, swelling, or tenderness

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

What is normal tone over normal lung tissue

Resonance

When percussing the posterior lung fields, which of the following findings is expected?

Resonance over all lung fields

The nurse asks the client to "raise the arm out to the side" in the position shown. What is the nurse assessing?

Shoulder abduction

A client is concerned about a dark skin lesion on their anterolateral abdomen. The lesion has not changed, nor is there any discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion?

Supernumerary nipple

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

When the nurse moves the client's arm from the midline of the body, the nurse is preforming

abduction

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

ask the client to breathe deeply through their mouth.

A nurse performs a nudge test to assess the gait of a client with Parkinson's disease. Which action by the nurse demonstrates the correct technique for performing this test? The nurse should stand:

at the back of the client and nudge the sternum

The major artery that supplies blood to the arm is the

brachial artery.

The size and shape of the breasts in females are related to the amount of

fatty tissue.

The functional part of the breast that allows for milk production consists of tissue termed

glandular

When the nurse moves a client's leg upward, the nurse is performing

supination

After assessing the breasts of a female client, the nurse should explain to the client that most breast tumors occur in the

upper outer quadrant.

The nurse is preparing to auscultate the lung sounds of a client. Which sound will the nurse expect to hear over most of the client's lungs?

vesicular