health assessment practice quizzes

erb's point

(S1, S2) left 3rd intercostal space

grades of murmurs

1 through 6

regurgitation

a backward flowing, as in the return of solids or fluids to the mouth from the stomach or the back flow of blood through a defective heart valve

thrombosis

a blood clot that adheres to the wall of a blood vessel, usually a vein

tympany

a clear hollow drum-like note heard during percussion over gas-filled organs, such as the stomach and bowels

pneumothorax

a collection of air in the pleural cavity, "collapsed lung"

bruit

a murmur like sound of vascular origin

thrill

a palpable vibration felt over the precordium or an artery due to blood turbulence, associated with grade 4-6 heart murmurs

palpitations

a sensation of rapid or irregular beating of the heart. the patient may describe the sensation as thudding, fluttering, or throbbing under the sternum

edema

abnormal accumulation of fluid in the intercellular spaces of the body

a hospitalized client experiences respiratory distress. the nurse should include which most appropriate client outcome in the plan of care?

airway, patent, breathing quiet, denies dyspnea

tachycardia

an abnormally fast heartbeat, usually over 100 beats per minute

An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible

angina

precordium

are on the anterior chest that overlies the heart and great vessels

what would the nurse expect to assess when examining the eyes of a client who reports a a history of severe allergies?

areas of dryness

A nurse experiences difficulty with palpation of the apical impulse on the precordium. What is an appropriate action by the nurse?

ask the client to assume left lateral position

a client complains of excessive tearing of the eyes. which assessment would the nurse do next?

assess the nasolacrimal sac

diaphragm of stethoscope

better for picking up high pitched sounds of S1 and S2 and murmurs or aortic and mitral regurgitation, firm pressure to the chest.

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

blood pressure

cyanosis

bluish discoloration fo tissue indicating hypoxia

sighing respiration

breathing punctuated by frequent sighs

The nurse hears a distinctive first heart sound while auscultating a client's heart rate. What does this heart sound represent?

closure of mitral valve

when caring for a client with chronic shortness of breath, fatigue is an issue. how might the nurse limit fatigue and still gather assessment information needed for daily care?

cluster care during times when the client is more rested

scaphoid

concave or hollowed

systole

contraction of the heart muscle

a mother brings her 2 year old child to the clinic stating that the child is cross-eyed. what test would the nurse perform to test for strabismus?

corneal light reflex

When auscultating a client's heart sounds the nurse detects a murmur that is initially loud and then gets softer. The nurse determines the pattern of this murmur to be which of the following?

crescendo-decrescendo

pectus excavatum

depressed lower portion of sternum, "funnel chest"

which action by the nurse indicates the appropriate use of opthalmoscope?

employ right eye to examine client's right eye

kyphosis

exaggerated outward or convex curvature of thoracic spine

bronchiol lung sounds

expiratory sounds are longer than inspiratory sounds, heard over the manubrium, if at all

adventitious lung sounds

extra sounds

when using PERRLA, the nurse is assessing which body part?

eyes

a patient has been found to have abnormal vision. what would be the nurse's next step?

facilitate a referral to an opthalmologist

the nurse is preparing to test a client's eyes for accommodation. the nurse would have the client focus on an object in which sequence for this test?

far, then near

what information, acquired during an eye assessment and history, would the nurse document as lifestyle habits?

has smoked for last 12 years uses sunglasses when outdoors uses protective eyewear when appropriate

A client complains of palpitations and a feeling of anxiety. Which of the following would be most appropriate for the nurse to keep in mind?

heart is attempting to increase cardiac output

A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

impaired gas exchange

barrel chest

increased anteroposterior diameter, normal during infancy, accompanies chronic pulmonary obstructive disease in aging.

thrombophlebitis

inflammation of a vein in conjunction with the formation of a thrombus

bronchitis

inflammation of the mucous membrane of the bronchial airways, caused by irritation or infection

vesicular lung sounds

inspiration is longer than expiration, heard over most of lungs, bilaterally

bronchiovesicular lung sounds

inspiratory and expiratory sounds are about equal, heard over the 1st and 2nd intercostal spaces and between the scapulae

tracheal lung sounds

inspiratory and expiratory sounds are about equal, heard over the trachea in the neck

ataxic or biot breathing

irregular breathing, periods of apnea with regular deep breaths which stop suddenly with short intervals

dyspnea

labored or difficult breathing, shortness of breath

what structure in the inner ear senses the position and movements of the head and helps maintain balance?

labyrinth

scoliosis

lateral curvature of the spine

when performing a physical examination for a client with scoliosis, which physical characteristic should the nurse expect to find during the assessment?

lateral deviation of the spinous processes

pulmonic auscultation

left 2nd intercostal space

mitral auscultation

left 5th intercostal space, medial to midclavicular line

tricuspid auscultation

lower left sternal border. 4th intercostal space

A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following?

mitral stenosis

bell of stethoscope

more sensitive to low pitched sounds of the S3 and S4 and the murmur of mitral stenosis, light pressure to the chest.

traumatic flail chest

multiple rib fractures that may result in paradoxical movements of the thorax

apnea

no breathing

symmetry

opposite sides compared to assess equivalence in size, shape, and position.

fatigue

overwhelming sense of exhaustion

a client has presented with "a terrible head cold," and the nurse is assessing for signs and symptoms of sinusitis. the nurse should utilize what assessment techniques?

palpation transillumination percussion

cheyne-stokes breathing

periods of deep breathing alternate with periods of apnea

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause?

pneumothorax

apical impulse

point of maximal impulse, approximately below the left nipple

a nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. what health promotion and prevention activity should the nurse encourage these clients to perform?

post an Amsler grid in their home and perform the test on a regular basis

diaphoresis

profuse sweating

obstructive breathing

prolonged expiration due to narrowed airways with an increased resistance to air flow

resonance

quality of sound heard during percussion of normal lung

hyperventilation

rapid deep breathing independent of metabolic demand except in respiratory acidosis

hypernea

rapid, deep breathing in response to metabolic demand such as exercise, high altitude, sepsis, and anemia

tachypnea

rapid, shallow breathing

the results of a Rinne test show bone conduction is greater than air conductino. which of the following would be most appropriate?

refer the client for further evaluation

assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. on further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. how should the nurse follow up this assessment finding?

refer the client to her primary care provider promptly.

jugular venous pressure

reflects right atrial pressure, and in turn equals central venous pressure and right ventricular end-diastolic pressure

diastole

relaxation of the heart muscle

aortic auscultation

right 2nd intercostal space

bradypnea

slow breathing, with or without an in crease in tidal volume

bradycardia

slow heartbeat, usually less than 60 beats per minute

stasis

slowed or stopped flow; for example, blood flow in veins

when preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces?

sternal angle

which accessory muscles are most important when considering inspiratory breathing needs during exercise?

sternocleidomastoids

pectus carinatum

sternum is displaced anteriorly, "pigeon chest"

A nurse is working with an older client who has decreased left ventricular compliance. The nurse understands that this condition will cause a decrease in the amount of blood pumped from the heart with each contraction, a measure known as which of the following?

stroke volume

when assessing the ear, which finding would be cause for concern?

tender tragus

contractility

the ability of the heart muscle fiber to stretch during ventricular filling; in the healthy heart the stretch is proportional to the force of contraction; the intrinsic ability of cardiac muscle to develop force for a given muscle length

stroke volume

the amount of blood ejected by the left ventricle with each contraction

which assessment observation should suggest that the client may be experiencing chronic obstructive pulmonary disease?

the chest is measured to be deeper than it is wide

stenosis

the constriction or narrowing of a passage or orifice, for example, a heart valve or blood vessel

preload

the end-diastolic stretch of a heart muscle fiber; end-diastolic volume

syncope

the transient and usually sudden loss of consciousness, accompanied by an inability to remain standing; fainting

fibrillation

uncoordinated electrical activity of the heart; quivering or spontaneous contraction of individual muscle fibers, which can be atrial or ventricular

When performing an adult cardiac examination and listening to the S1 and S2, the nurse may (Select all that apply.)

use diaphragm of stethoscope use bell of stethoscope pressed firmly on the chest

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply.

use relaxation techniques to manage stress eat foods low in sodium walk for at least 30 minutes/day

Which statement is true regarding client positioning when attempting to identify intercostal spaces during a respiratory assessment?

women should be assess while in a supine position.