Health Assessment Exam 2 Quizzes

The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client?

"You have a conductive hearing loss."

Do these to help with what aspect of assessment? •Eliminate distracting noises from the environment •Readjust the ear pieces to ensure a snug fit •Angle the binurals towards the nose

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones?

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's a) vesicles b) bullae. c) nodules. d) wheals.

A) Vesicles

What would be the expected tone elicited by percussion of a normal lung? A. Resonance B. Tympany C. Hyper-resonance D. Dullness

A. Resonance

Which of the following cranial nerves innervated the lateral rectus muscle of the eye, allowing for lateral vision? Abducens(VI) Trochelear (IV) Oculomotor (III) Optic (II)

Abducens(VI)

During the physical assessment of Jennifer Aniston, during the inspection phase, the nurse notices that her skin is pale. The nurse expects that Jennifer may have: Jaundice Pulmonary Edema Anemia An Erythematous Rash

Anemia

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter An important component of chest inspection is assessment of the anteroposterior diameter versus the transverse diameter. This is achieved by viewing the client from the back and side. Costochondral inflammation and tracheal position are not assessed in this way, and assessment of the cervical spine is not a central goal of thoracic inspection

The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? Shock Walking Bleeding Anxiety

Anxiety

The nurse is preparing to examine the skin of an adult client with a elevated nevus (birthmark/mole). The nurse plans to measure the client's lesion. What would indicate an abnormality? Color is uniform Diameter less than 1/4 of an inch Borders well demarcated (separate or distinguish from) Asymmetrical shape

Asymmetrical shape

Connecting the skin to underlying structures is/are the a) sebaceous glands. b) subcutaneous tissue. c) papillae. d) dermis layer.

B) Subcutaneous tissue

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of: A. Papules B. Macules C. Bulla D. Plaques

B. Macules

While examining a client, the nurse plans to palpate temperature of the skin by using the A. ulnar surface of the hand. B. dorsal surface of the hand. C. fingertips of the hand. D. palmar surface of the hand.

B. dorsal surface of the hand.

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment? A. Doppler B. stethoscope bell C. sphygmomanometer D. stethoscope diaphragm

B. stethoscope bell

What can the nurse assess using percussion? Borders of the heart Movement of the diaphragm during expiration Strength of the pulse Rectal distension

Borders of the heart Percussion allows the examiner to assess such normal anatomic details as the borders of the heart. Options B, C, and D are incorrect because they cannot be assessed by percussion.

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? Exposure of subcutaneous tissue and muscle Unbroken but red in color Ulceration resembling a crater Broken with the presence of a blister

Broken with the presence of a blister

Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration. • Bronchovesicular • Vesicular • Bronchial • Tracheal

Bronchial These characteristics are consistent with bronchial breath sounds. Be alert for these because they may occur elsewhere and indicate pneumonia or other pathology. The current explanation for this phenomenon is that fluid carries the sound from the trachea very well to the chest wall. This same explanation explains 'ee' to & 'aa' changes, whispered pectoriloquy, bronchophony, and others in which high-frequency sounds, normally blocked by air-filled alveoli, could be transmitted to the chest wall.

The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what? Bruit Borborygmi Venous hum Friction rub

Bruit Bruits are swishing sound that indicate turbulent blood flow. Borborygmi is increased bowel sounds. A venous hum is a soft-pitched humming sound associated with partial obstruction of an artery and reduced blood flow to the organ. Friction rubs are a grating sounds with inspiration.

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

Bruits

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? A. Flatness B. Dullness C. Resonance D. Tympany

C. Resonance

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's A. lungs. B. abdomen. C. bone. D. liver.

C. bone.

The nurse is performing the Romberg test. Which of the following indicate a normal finding? Client stands erect with minimal swaying Client sways when eyes are closed Client prevents himself from falling Client maintains balance when walking

Client stands erect with minimal swaying

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding? Fine crackles Coarse crackles Sibilant wheeze Sonorous wheeze

Coarse crackles

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds? Coarse crackles Pleural friction rubs Sonorous wheezes Sibilant wheezes

Coarse crackles Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound that is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low-pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration.

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order). a. over most of both lungs b. between the scapulae c. over the manubrium d. over the trachea in the neck 1a, 2c, 3b, 4d 1a, 2b, 3d, 4c 1c, 2b, 3a, 4d

Correct! 1a, 2b, 3c, 4d

A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? Cranial nerve I (olfactory) Cranial nerve X (vagus) Cranial nerve VII (facial) Cranial nerve XII (hypoglossal)

Cranial nerve XII (hypoglossal) Decreased tongue strength may occur with a defect of the twelfth cranial nerve—hypoglossal—or with a shortened frenulum that limits motion. Receptors of cranial nerve I (olfactory) are located in the nose. These receptors are related to the sense of smell. A loss of taste discrimination occurs with a defect of cranial nerve VII (facial). The palate fails to rise and the uvula deviates to the side with cranial nerve X (vagus) paralysis.

the skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin _. a) A b) C c) D

D

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit A. dullness. B. tympany. C. flatness. D. hyperresonance.

D. hyperresonance.

Which of the following is not a condition that could lead to a Barrell Chest? Chronic Asthma Emphysema Deep Breathing Normal Aging

Deep Breathing

Hair follicles, sebaceous glands, and sweat glands originate from the Dermis Subcutaneous Epidermid

Dermis

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

Disinfect the stethoscope before touching the client

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

The nurse is conducting a physical examination of a patient who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position? Range of motion of the spine Posterior chest excursion Head and neck range of motion Dorsiflexion of the foot

Dorsiflexion of the foot Assessment of dorsiflexion can offer information about problems with the cardiovascular and musculoskeletal systems. Dorsiflexion is best assessed when the client is lying down. Spine range of motion is assessed with the patient in the standing position. Posterior chest excursion and head and neck range of motion are assessed with the patient in the sitting position.

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure? Application of firm pressure when using the bell Using the diaphragm to listen to low-pitched sounds Using the bell to detect high-pitched sounds Ensuring that contact with the skin is maintained

Ensuring that contact with the skin is maintained While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.

These are examples of? The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic lub-dub over the patient's anterior thorax. The nurse notes gurgling sounds over the individual's abdomen.

Examples of auscultation

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

Which of the following cranial nerves would be best assessed by smiling? Facial (VII) Trigeminal (V) Hypoglossal (XII) Glossopharyngeal (IX)

Facial (VII)

When assessing pulses, the nurse would use which part of the hand for palpation? A. Palmar surface B. Ulnar surface C. Fingerpads D. Dorsal surface

Fingerpads

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 • Fluid in the bronchioles • Fluid in the bronchus • No fluid present

Fluid in the alveoli When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds. Fine crackles are not indicative of fluid in the bronchioles or bronchus or the absence of fluid in the lungs

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury? Vagus (X) Spinal accessory (XI) Glossopharyngeal (IX) Hypoglossal (XII)

Glossopharyngeal (IX)

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur

Asking a patient to stick out and move their tongue would assess which of the following cranial nerves? Facial (VII) Hypoglossal (XII) Abducens (VI) Trigeminal (V)

Hypoglossal (XII)

Which of the following assessments would be most applicable for the trigeminal nerve (V)? Puffing out their cheeks Sticking out their tongue. Rolling their eyes downward and inward. Identifying sharp vs dull contact on the face.

Identifying sharp vs dull contact on the face. Puffing out their cheeks- Facial nerve Sticking out their tongue- glossalpharingeal and hypoglossal Rolling their eyes downward and inward- oculomotor nerve

What assessment technique is performed for every body part and body system?

Inspection

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment Auscultation palpation Inspection Percussion

Inspection, palpation, percussion, auscultation Inspection is the first physical assessment technique that a nurse should implement. This prevents altering the appearance of structures that may distract the nurse from completing a focused observation.

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? - Listen again with the bell of the stethoscope - Instruct the client to cough forcefully - Have the client breathe through the mouth - Assess for the use of accessory muscles

Instruct the client to cough forcefully When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress.

Which of the following is not a descriptor for quality of cough? Wet Length Pitch Dry

Length

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 - Move from anterior to posterior on the same side - Instruct the client to breathe in and out rapidly through the mouth - Use the diaphragm then the bell in each location

Listen at each site for at least one complete respiratory cycle The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds.

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds Hold bell lightly over what is being auscultated

As the density of tissue decreases, the percussion note becomes:

Lower pitched

A nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? - Fluid in the alveol i- Blockage of a respiratory passage - Decreased compliance of the lungs - Narrowing or partial obstruction of an airway passage

Narrowing or partial obstruction of an airway passage The auditory characteristics of wheezing result from narrowing of the lumen of a respiratory passage. Fluid in the alveoli results in crackles, and complete obstruction causes an absence of breath sounds. Decreased lung compliance compromises ventilation but does not necessarily result in wheezes.

Decreased Fremitus related to decreased air movement is caused most likely cause by... Compression of lung tissue Obstruction Consolidation of lung tissue Pneumonia

Obstruction

A Snellen chart would assess which of the following nerves related to eye function? Oculomotor (III) Trochlear (IV) Abducent (VI) Optic (II)

Optic (II)

Which of the following would be best for a nurse to use when assessing for fremitus in a client? - Dorsal hand surface - Pads of fingers - Palmar base (ulnar surface) - Fist

Palmar base (ulnar surface) The palmar base or ulnar surface of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation. The dorsal surface of the hand is used to assess temperature. The fist is used in blunt percussion. Fingerpads are used for fine discrimination such as pulses, texture, and size.

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

Palpation

Which term provides confirmation of data you have visualized? Auscultation Palpation Percussion Inspection

Palpation

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area? palpation inspection percussion auscultation

Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. •Percussion is used to illicit sound or determine tenderness. •Auscultation is used to listen to sounds.

An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. The nurse would document this finding as which of the following? a) Macule b) Nodule c) Papule d) Pustule

Papule

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a: Macule Patch Papule Plaque

Papule

The term Pigeon Breast is commonly used to describe which condition? Pectus Carinatum Barrel Chest Pectus Excavatum Kyphosis

Pectus Carinatum

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using inspection. palpation. Doppler magnification. percussion.

Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? Purpura Cherry Angioma Ecchymosis Petechiae

Petechiae

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 The correct technique for assessment of chest expansion is for the examiner to place the hands on the posterior chest wall with thumbs at the level of T9 or T110 and pressing together a small skin fold. Ask the client to take a deep breath and observe the movement of the thumbs. Using the ball of the hand to feel vibration tests for tactile fremitus.

Which action by a nurse demonstrates proper technique for assessment of symmetric expansion? Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest Place both hands on the posterior chest at T9-T10, press thumbs together, and then ask client to take a deep breath

Place both hands on the posterior chest at T9-T10, press thumbs together, and then ask client to take a deep breath

When using the diaphragm of the stethoscope, it's important to ... Press firmly to listen for low pitched sounds Press lightly to hear abnormal heart sounds Press firmly to listen for high pitched sounds Press lightly to hear normal bowel sounds

Press firmly to listen for high pitched sounds When using the bell of stethoscope- hold bell lightly and listen for low pitch sounds

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? Percuss the region before auscultating. Palpate the region before auscultating. Assist the client to a sitting position. Reduce all environmental noise.

Reduce all environmental noise. Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the patient to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the patient in the lying position.

Professor Von Schweetz was scheduled for a physical assessment. When percussing the patient's chest, the nurse would expect to find which assessment data as a normal sign over his lungs? Resonance Dullness Hyperresonance Tympanic

Resonance

When percussing the posterior lung fields, which of the following findings is expected? - Hyperresonance over apices - Dullness over the lung bases - Resonance over all lung fields - Tympany over 11th interspace, right scapular line

Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological.

A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?

Romberg

A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance?

Romberg test

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Squamous Cell Sebum Production Sweat Glands Subcutaneous Tissue

Sebum Production

For which assessment would the nurse plan to use direct percussion?

Sinuses The nurse performs direct percussion by tapping the fingers directly on the patient's skin, such as for assessment of the sinuses. The nurse performs indirect percussion by using the non-dominant hand as a barrier between the nurse's dominant hand and the patient to assess organs, such as the gallbladder, kidneys, and liver.

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart This is also for Optic nerve- visual acuity

What is used to gauge central and peripheral nervous system disorders? Strength of a reflex Gait Tuning fork Heat and cold

Strength of a reflex

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? Stridor Crackles Wheezes Rales

Stridor Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.

The nurse detects gurgling throughout the abdomen is an example of what?

Technique of auscultation

The nurse notes resonance over the individual's thorax is an example of?

Technique of percussion

You should use the bell of the stethoscope when auscultating what type of sounds? Abnormal sounds High-frequency sounds Low-frequency sounds Sounds that are partially audible without a stethoscope

The bell is used with light skin contact to hear low-frequency sounds.

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement, by the client, would guide the nurse's use of a stethoscope during this phase of assessment? A. The binaurals connect the tubing to the chest piece. B. The diaphragm should be held firmly against the body part. C. Auscultation can be performed through clothing. D. The bell of the stethoscope can detect bowel sounds.

The diaphragm should be held firmly against the body part.

A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions? a) The lesions will not be palpable .b) The lesions will be raised and have irregular borders. c) The lesions will produce eschar. d) The lesions will be acutely painful.

The lesions will not be palpable .Explanation: Macules are small, flat, nonpalpable areas of skin color change. They are not normally painful and do not produce eschar.

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique? One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. The middle finger of one hand is placed on the body surface and the other middle finger strikes. The ulnar surface of one hand is placed against the body surface and vibrations are felt. One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.

The middle finger of one hand is placed on the body surface and the other middle finger Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand being placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and striking the back of the flat hand with the fist of the other hand.

Which of the following is not true of advanced clubbing nails? The nail bed angle is less than 60 degrees Related to lung disorders It is a objective finding Nails become spongy

The nail bed angle is less than 60 degrees

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.

Which is an example of auscultation? Select all that apply. The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic heart beat over the patient's anterior thorax. The nurse notes hyperresonance over the patient's thorax. The nurse detects tympany over the patient's lower abdomen.

The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic heart beat over the patient's anterior thorax. hyperresonance, and tympany are percussion

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

What is the principle of percussion? To assess the sound created by the body To strike the abdominal wall with a soft object To create sound over dead spaces in the body To create vibration in a body wall

To create vibration in a body wall The principle of percussion is to set the chest wall or abdominal wall into vibration by striking it with a firm object.

While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

To determine whether a structure is filled with air or fluid or is a solid structure

T/F: use deep palpation for deep organs or structures that are covered by thick muscle (abdominal organs)

True: • Light (< 1 cm) & Moderate (1-2 cm) palpation- pulses, tenderness, surface skin texture, temperature, and moisture. Note size,consistency, mobility (lymp nodes). Moderate us a circular motion • Deep palpation (2.5-5 cm)• Bimanual palpation- Two hands on each side to note size, shape, structure, mobility (breasts, spleen, kidneys/flank pain)

a nurse is palpating a client's chest for vibration as he inhales and exhales. which part of the hand should the nurse use in this case?

Ulnar/palmar surface

A client tells the nurse that it is difficult to hear normal conversation when in a room with a lot of noise. Which test should the nurse perform to assess the hearing ability of the client?

Weber

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Webers test

Opens eyes and answers questions but falls back asleep is known as _____ a) Lethargy b) Obtunded c) Mental disorder

a) Lethargy

Slow response, mumbles and incoherent, opens eyes to loud voice is known as _____ a) Obtunded b) Alert c) Stupor d)Lethargic

a) Obtunded

Percussion Sounds Elicited: Intensity: Loud Pitch: Low Length: Long Quality: Hollow ex: normal lung a) Resonance b) Hyper-resonance c) Tympany d) Dullness e) Flatness

a) Resonance

The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score? a) eye opening, and appropriateness of verbal and motor responses b) ability to recall recent and remote memories, and to use abstract reasoning c) assessment of the 12 cranial nerves d) naming of objects, recall of three words, and the ability to draw a design

a) eye opening, and appropriateness of verbal and motor responses

This palpation utilizes two hands. a) bimanual palpation b) bilateral palpation c) Two-handed technique

a)bimanual palpation

A macule is an elevated, palpable, solid mass with a circumscribed border. a. False b. True

a. False Macule is non elevated less than 1cm in diameter and only a change in color- freckle

What should the nurse assess to test the function of the occipital lobe? Impulses from the ear Communication Tactile sensation Ability to read

ability to read

Percussion Sounds Elicited: Intensity: very Loud Pitch: Low Length: Long Quality: Booming ex: lung w/ emphysema a) Resonance b) Hyper-resonance c) Tympany d) Flatness

b) Hyper-resonance

When collecting objective data what should be performed first?a) Palpation b) Inspection c) Assessment d) Percussion

b) Inspection

Awakens to painful stimuli and then goes back to sleep; has motor response of withdrawal, groans or mumbles is known as _____ a) Alert b) Stuporous c) Coma d) Lethargic

b) Stuporous

An elevated, circumscribed, fluid filled lesion; greater than 1 cm in diameter a) wheal b) bulla c) papule

b) bulla

Solid, elevated, circumscribed, superficial lesion; less than 1 cm in diameter a) urticaria b) papule c) wheal

b) papule

The nurse is watching a new graduate nurse perform auscultation of a patients abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a.We need to determine the areas of tenderness before using percussion and palpation. b.Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation. c.Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination. d.Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.

b. Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation. NOT THE LONG ONE

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing

b. Friction rub A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds: a.Are usually loud, high-pitched, rushing, and tinkling sounds. b.Are usually high-pitched, gurgling, and irregular sounds. c.Sound like two pieces of leather being rubbed together. d.Originate from the movement of air and fluid through the large intestine.

b.Are usually high-pitched, gurgling, and irregular sounds.

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is: tachycardia bradycardia weak and thready sinus arrhythmia.

bradycardia

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what? - Bradypnea- Tachypnea- Hyperventilation- Hypoventilation

bradypnea A respiratory rate of less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased, with a decrease in depth and with an irregular pattern.

Unresponsive to all stimuli is known as _____ a) Lethargy b) Obtunded c) Coma

c) Coma

Percussion Sounds Elicited: Intensity: Loud Pitch: high Length: moderate Quality: drum-like ex: puffed out cheek/gastric bubble a) Resonance b) Hyper-resonance c) Tympany d) Dullness e) Flatness

c) Tympany

___: Physical Examination Stethoscope is used to listen for body sounds that cannot ordinarily be heard without amplification: • Heart & lung sounds, bruits, bowel sounds,Expose the body part being listened to Diaphragm: high-pitched sounds (breath sounds) Bell: light pressure for low-pitched sounds (bruits) a) percussion b) palpation c) auscultation d) all of the above

c) auscultation

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 1 cm. The nurse documents this as a ... a) macule b) papule c) plaque

c) plaque

Elevated, solid, transient lesion; often irregularly shaped; an edematous a) bulla b) keloid c) wheal

c) wheal

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

c, d, e, b, a Explanation: When conducting a head-to-toe assessment for a patient in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Cheyne-Stokes respirations c. Hypoventilation d. Chronic obstructive breathing

c. Hypoventilation Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. (See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.)

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a.Flatness, resonance, and dullness. b.Resonance, dullness, and tympany. c.Tympany, hyperresonance, and dullness. d.Resonance, hyperresonance, and flatness.

c. Tympany, hyperresonance, and dullness.

When auscultating a client's lungs, the nurse hears a loud popping sound that clears when the client coughs. What sound is this client most likely demonstrating? • rhonchi • wheezes • fine crackles • coarse crackles

coarse crackles • Coarse crackles change or disappear with coughing. Rhonchi are a variation of wheezes but are lower in pitch. They may also disappear with coughing. Wheezes are continuous musical sounds. Fine crackles are soft, high-pitched and change according to body position.

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing a) normal hearing. b) central hearing loss. d) conductive hearing loss. d) sensorineural hearing loss.

conductive hearing loss.

Percussion Sounds Elicited: Intensity: medium Pitch: medium Length: moderate Quality: thud-like ex: diaphragm, pleural effusion, liver a) Resonance b) Hyper-resonance c) Tympany d) Dullness e) Flatness

d) dullness

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing light palpation. moderate palpation. deep palpation. very deep palpation.

deep palpation. Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

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Hair follicles, sebaceous glands, and sweat glands originate from the ....a) epidermisb) keratinized tissuec) dermis

dermis

Which of the following is a percussion type: a) Direct b) Blunt c) Indirect or mediate d) Sounds elicited bypercussion e)Resonance, hyper- resonance, tympany, dullness, or flatness f) all of the above

f) all of the above

Which of the following should be taken in consideration when percussing: a) Eliciting pain b) Determining location, size, and shape c) Determining density• Air or fluid or is a solid structure d) Detecting abnormal masses e) Eliciting reflexes• Percussion hammer for deep tendon reflexes f) all of the above

f) all of the above

what part of the hand is sensitive to fine discriminations; pulses, textures, size, consistency, shape and crepitus

finger-pads

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis? - Friction rub- Decreased breath sounds- Sibilant wheeze- Stridor

friction rub In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngospasms, such as croup.

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the vagus. hypoglossal. trigeminal. glossopharyngeal.

glossopharyngeal The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated.

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? Romberg Tandem walking Gait Hop on one foot

hop on one foot

Light palpation is most appropriate to assess the A. liver B. bladder C. appendix D. inflamed areas of skin

inflamed areas of skin

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition? • ineffective innervation of the of the parietal pleura by the phrenic nerve • an accumulation of fluid between the lungs and the visceral pleura • inflammation of the parietal pleura • an increase of sensory stimulation in the visceral pleura

inflammation of the parietal pleura

What physical assessment technique should a nurse use to obtain a pulse on a client? Light palpation Moderate palpation Deep palpation Bimanual palpation

light palpation The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpation is used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a: plaque. macule. papule. patch.

papule.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a a) patch. b) plaque. c) macule. d) papule.

papule. Explanation: Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination? Percussion Palpation Auscultation Inspection

percussion

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound? • sound heard throughout inspiration and two thirds of expiration • inspiratory and expiratory sounds equal in length • expiratory sounds lasting longer than inspiratory • short silence between inspiration and expiration

sound heard throughout inspiration and two thirds of expiration

A client blinks when the right eye is lightly touched with a cotton wisp. Which cranial nerve should the nurse document as being intact? trochlear abducens trigeminal oculomotor

trigeminal The trigeminal nerve has 2 functions - motor and sensory. There are three branches to the sensory function. One of these branches innervates the eye and is responsible for the expected response of a blink when testing the corneal reflex. The trochlear nerve is responsible for the downward, internal rotation of the eye. The abducens nerve is responsible for lateral deviation of the eye. The oculomotor nerve is responsible for pupillary constriction, opening the eye, and most extraocular movements.

what part of the hand do you use to feel vibrations, thrills, fremitus?

ulnar or palmar surface

Which assessment observation should suggest that the client may be experiencing chronic obstructive pulmonary disease (COPD)? • The trachea is displaced laterally .• The chest is measured to be deeper than it is wide. • There is a unilateral decrease in chest expansion. • There is tenderness over rib area.

• The chest is measured to be deeper than it is wide.