Holistic Assessment Exam #3 Practice

Pulmonary veins return blood to the...

left atrium

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

left midclavicular line at the fifth intercostal space

The deoxygenated blood is transported via the pulmonary artery to the...

lungs

The nurse is conducting a workshop on the measurement of jugular venous pulsation. As part of instruction, the nurse tells the students to make sure that they can distinguish between the jugular venous pulsation and carotid pulse. Which of the following characteristics is typical of the carotid pulse?

palpable

What symptom is a hallmark of acute pulmonary edema?

pink, frothy sputum

Pain associated with angina pectoris is...

pressure-like

Deoxygenated blood arrives at the pulmonary artery via the...

pulmonic valve

Which of the following are risk factors for Coronary Artery Disease (CAD)? Select all that apply.

-Diabetes -Sedentary lifestyle -Hormone replacement therapy -High-stress job

What is the best position for the patient to assume during a retraction screening?

sititing position

A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about this lump?

size

A nurse teaches a client about breast self-examination. What should the nurse tell the client about examining the underarm? The arm should be:

slightly raised

After circulating throughout the body, deoxygenated blood returns to the right atrium via the...

superior vena cava

The right 2nd rib space is the first location for cardiac auscultation and is also known as:

the aortic area.

A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?

"The area of cramping is close to the area of arterial occlusion."

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what?

Angina Angina is temporary heart pain, resolving in less than 20 minutes. It can be aggravated by physical activity and stress, or there may be no triggers (unstable angina). This type of pain is not musculoskeletal, gastrointestinal, or crushing.

When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:

Aortic and pulmonic

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

Bruits

Cheyne-Stokes

Alternating periods of deep, rapid respirations followed by periods of apnea

Which of the following disorders is associated with intermittent claudication?

Arterial insufficiency

How can the provider screen for heart disease in an infant client?

Ask about fatigue during feeding

How should a nurse assess a client for pulse rate deficit?

Assess for a difference between the apical and radial pulse

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Assist the client to walk as soon and as often as possible.

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?

Auscultate to determine the heart rate and if the rhythm is normal

How can the provider assess for a bruit?

Auscultate with the bell of the stethoscope

A 72-year-old retired saleswoman comes to the office with a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The client denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetrical with no skin changes. The nurse can express bloody discharge from the client's left nipple. No discrete masses are palpable, but her left axilla has a hard 1-cm fixed node. The remainder or her heart, lung, abdominal, and pelvic examinations are unremarkable. What is the most likely cause of nipple discharge in her circumstance?

Breast cancer

During the health interview, the nurse asks a patient at what age she experienced the onset of menarche. This question addresses a risk factor for what health problem?

Breast cancer

Older adults tend to get arteriosclerosis. What is the cause of this disease process?

Calcification of the arteries Calcification of the arteries causes them to become more rigid in older adults. Atherosclerosis is the buildup of plaque in the arteries. High-fat diets contribute to atherosclerosis. Low LDL is a beneficial finding and does not contribute to cardiovascular problems.

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?

Cheyne-Stokes

A nurse understands that the cardiac event that cycles the beginning of systole is what?

Closure of the mitral and tricuspid valves

During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus?

Decreased The nurse should find decreased fremitus in the client diagnosed with pneumothorax. Fremitus is the vibration of air in the bronchial tubes transmitted to the chest wall which is normally symmetrical. Unequal fremitus can be increased or decreased as a result of consolidation, bronchial obstruction, air trapping due to emphysema, pleural effusion, or pneumothorax. Absence of fremitus is not a physiological finding.

A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency?

Deep ulcers that often involve joint space

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Dyspnea

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

Elevated pressure related to heart failure.

Inspection of the breast is done with the client in a supine position. (T or F)

False

To function adequately, the nurse knows that the heart valves need to open simultaneously. (T or F)

False

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

Fifth left intercostal space at the midclavicular line

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

Friction rub

While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. What action would the nurse do first?

Have the client cough, then listen again

During the health interview, a client tells the nurse that he "can't breathe all that well" at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for what health problem?

Heart failure

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

Hyperresonance

A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. Examination shows a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. What is the most likely cause of his gynecomastia?

Imbalance of hormones of puberty

How can the provider assess central venous pressure?

Inspection

How can the provider assess for a heave?

Inspection

Biot

Irregular pattern of respirations with varying depth and rate followed by periods of apnea

To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment?

Jugular venous pulse

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

The nurse is preparing to auscultate the client's thorax. What action is the priority during this component of assessment?

Listen at each site for at least one complete respiratory cycle

A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?

Lymphadenopathy of infectious origin

A nurse expects to find which abnormal heart sound in a client diagnosed with mitral valve prolapse?

Midsystolic click

A 25-year-old optical technician comes to the clinic for evaluation of fatigue. As part of the physical examination, the nurse listens to her heart and hears a murmur only at the cardiac apex. Which valve is most likely to be involved based on the location of the murmur?

Mitral

Variations in the presentation of S1 are due to alterations in which heart valve?

Mitral valve

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

Normal finding

A 50-year-old female presents to the health care clinic as a new client for a complete physical examination. Which data in her health history should a nurse recognize as a risk factor for the development of breast cancer?

Nulliparity Nulliparity (no pregnancies) or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, and early menarche. Use of birth control pills has a slight increase in risk but mainly with long term use or high estrogen pills.

Which of the following assessment findings is most likely benign on breast examination?

One breast larger than the other

A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?

Opiates, which may cause hypoventilation

A nurse palpates a weak left radial artery on a client. What should the nurse do next?

Palpate both radial arteries for symmetry.

How can the provider assess for a thrill?

Palpation

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus?

Palpation

A nurse detects a bruit on auscultation of the carotid arteries. What precaution should the nurse take during the remainder of the physical assessment of the carotid arteries?

Perform palpation lightly

What is the most important physical sign of acute pericarditis?

Pericardial friction rub

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?

Peripheral vascular problems

When evaluating the jugular venous pressure in a client with known coronary artery disease, the nurse explains to the client that the JVP measures the pressure in the

Right atrium

The direction of blood flow through the heart is best described by which of the following options?

Right atrium → right ventricle → pulmonary artery → lungs → pulmonary vein → left atrium → left ventricle

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

Pleurisy

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

What is the most important lifestyle changes a client can make to improve cardiovascular health?

Quitting smoking

Kussmaul

Rapid, deep, labored respirations

During the physical examination of a client's breast, which finding should the nurse recognize as a possible indication of a malignant tumor?

Retraction of nipples

A nurse teaches a group of young women about how to properly perform a self breast examination. How should the nurse explain the best time to perform the exam?

Right after the menstrual flow stops

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?

Shortness of breath

While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate?

Shortness of breath

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

Smoking, hypertension, obesity, diabetes, and high cholesterol

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

Sternal angle

When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start?

Sternal angle

The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be normal and would be seen in a healthy client?

The jugular venous pulse is not visible when the client is sitting upright

Where are the heart and great vessels located in the human body?

The mediastinum, between the lungs above the diaphragm

How would you describe your chest pain?

This can differentiate between cardiovascular, digestive, and musculoskeletal issues.

Have you noticed that your extraordinary fatigue occurs at a certain time of day?

This can differentiate between decreased cardiac output and depression

Is the edema in your lower extremities bilateral or unilateral?

This can differentiate between heart failure and venous obstruction

How far could you walk without shortness of breath 2 months ago?

This can provide insight into progression of dyspnea on exertion

Which vessels return the lymph fluid to circulation?

Thoracic ducts

How many lung lobes can be auscultated on the posterior chest?

Total: 4 lobes Rt lung: 2 lobes Lt lung: 2 lobes

How many lung lobes can be auscultated on the anterior chest? How many are on the Lt and Rt sides?

Total: 5 lobes Rt lung: 3 lobes Lt lung: 2 lobes

Symptoms of complete arterial occlusion include which of the following? Select all that apply. a. Numbness b. Color change c. Pain d. Erythema e. Heat

a,b,c

What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply. a. Skeletal muscle contraction b. Respiration c. Intraluminal valves d. Cardiac output e. Activity level

a,b,c

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply. a. Quit or do not start smoking b. Exercise regularly c. Undergo regular cholesterol screening d. Eat a low-fiber diet e. Undergo regular screening for diabetes

a,b,c,e

A client is concerned about a right breast lump. What questions can the nurse ask to effectively assess the associated manifestations of this mass? (Select all that apply.) a. "Is there pain with the lump?" b. "Is there any discharge from the lump?" c. "Does anything make the lump go away?" d. "How are you coping with the lump?" e. "Are you menstruating when the lump is present?"

a,b,e

Which of the following interventions can the nurse use to help a client modify risk factors associated with hypertension? (Select all that apply). a. Ask the client to keep a "typical day" record of daily food intake b. Ask the client to keep an activity log c. Encourage the client to quit alcohol consumption d. Encourage the client to limit consumption of potassium rich foods e. Provide information about aids to promote smoking cessation

a,b,e

A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Mark all that apply.) a. Inspection b. Pain c. Timing d. Palpation e. Pallor

a,c,d

What can the nurse recommend to a young female client who is seeking to reduce her risk for breast cancer? Select all that apply. a. Engage in regular, strenuous physical activity b. Increase the intake of fat in the diet c. Have children before 30 years of age d. Breast-feed if possible e. Regularly consume alcohol (two to five drinks daily)

a,c,d

Pain associated with musculoskeletal origins is....

aching

A patient presents with a squeezing chest pain that they described with a clenched fist?

angina

Oxygenated blood moves from the left ventricle through the...

aortic valve to the aorta

Which of the following veins drain into the superior vena cava? (Mark all that apply.) a. Lower extremities b. Upper torso c. Head d. Upper extremities e. Lower torso

b,c,d

A group of students is preparing for a quiz on breast assessment and the assessment findings that are associated with breast cancer. The students demonstrate understanding of the material when they identify which of the following? Select the 3 that apply. a. Redness and warmth with smooth texture b. Irregular, firm lumps c. Dimpling and nipple retraction d. Elastic, tender, mobile lumps e. Orange peel-like appearance

b,c,e

A nurse palpates the breasts of a client for masses during the physical examination. The nurse knows that if a tumor if malignant, which characteristics will be present? Select all that apply. a. rubbery and mobile b. hard and nontender c. fixed to underlying tissues d. well-demarcated borders e. irregular in shape

b,c,e

Pain associated with digestive issues is...

burning

What characteristic nail color should the nurse recognize as an indication of hypoxia?

cyanotic

Pain associated with a myocardial infarction is...

viselike

What breast changes occur in the aging female?

↓ glandular tissue ↑ fibrous connective tissue