Health Assessment Exam 3 test bank, Chapter 21: Abdomen (Health Assessment), Ch. 18PAD and PVD,
What does a positive Bloomberg sign indicate?
Peritoneal inflammation
Assessment reveals that an older client has osteomalacia. Which of the following would be most important to include in the client's teaching plan? A) Practice risk prevention for fractures. B) Keep exercise to a minimum to decrease pain. C) Minimize movements to maintain joint stability. D) The risk for arthritis increases with age.
a
During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve? A) CN I B) CN II C) CN VII D) CN IX
a
Kussmaul respiration
a type of hyperventilation that occurs with diabetic ketoacidosis
Shifting dullness is a test for _____.
ascites
A client's bladder is found to be distended. At which location would the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant
b
After teaching a group of students about the important organs to be assessed during an abdominal assessment, the instructor determines that the teaching was successful when the students identify which organ as the largest solid organ in the body? A) Pancreas B) Spleen C) Liver D) Kidney
c
angiography
contast dye used to follow blood flow
A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess? A) Knife-like pain B) History of fracture C) Recent weight gain D) Difficulty chewing
d
A nurse asks a client to bring the hands together behind the head with the elbows flexed. The nurse is testing which of the following? A) Abduction B) Adduction C) Internal rotation D) External rotation
d
Vital capacity
the amount of air following maximal inspiration that can be exhaled
endarterectomy
remove occlusive plaque, performed with cutting, disc, laser, or diamand tip
During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade? A) I B) II C) III D) IV
B) II
A 42-year-old woman reveals an intake of medications. Which medication if reported by the client would alert the nurse to the need to assess the client for thrombophlebitis? A) Antihypertensive B) Antidepressant C) Oral contraceptive D) Antilipid agent
c
A client complains of headaches each morning that disappear after getting out of bed. Which of the following would be most appropriate for the nurse to do? A) Assess if the headaches are accompanied by dizziness. B) Perform a complete neurologic exam. C) Refer the client for immediate follow-up. D) Ask if the client has ever had a seizure.
c
The nurse is palpating the pulse just under the inguinal ligament. The nurse is assessing which pulse? A) Temporal B) Brachial C) Popliteal D) Femoral
d
How to Dx VD
duplex ultrasound venogram
Risk factors for PVD and atherosclerosis
nicotine diet HTN diabetes obesity stress sedentary lifestyle C-reactive protein age, gender, genetics
The left upper quadrant (LUQ) contains the _____.
spleen
A dull percussion note forward of the left mid-axillary line is indicative of _____.
spleen enlargement
palpable with inflammation of the pleura
Pleural friction fremitus
What assessment finding will the nurse document in a patient with an aortic aneurysm?
Presence of bruit on auscultation.
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short-time hungry again. What other information would the nurse want to have?
Presence of dyspnea or diaphoresis wen sucking
duplex US
bidirectional, color doppler
Crepitus
coarse, crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue
A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? A) Posterior neck B) Axillary area C) Inguinal area D) Upper arm
d
A nurse is preparing to palpate a client's spleen. Which position would the nurse use to facilitate palpation? A) Sitting B) Lying prone C) Left side-lying D) Right side-lying
d
Acinus
functional respiratory unit that consists of the bronchioles, alveolar ducts, alveolar sacs, and the alveoli.
Xiphoid process
sword-shaped lower tip of the sternum.
Fissure
the narrow crack dividing the lobes of the lungs
occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). This is present only when the bronchus is patent and when the consolidation extends to the lung surface.
Increased fremitus
What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?
Listen with the bell of the stethoscope to assess for bruits
Patient is coughing up rust colored sputum? The color of the sputum is indicative of what conditions?
Tuberculosis or pneumonoccal pneumonia
Asthma
an abnormal respiratory condition associated with allergic hypersensitivity to certain inhaled allergens, characterized by bronchospams, wheezing, and dyspnea.
Atelectasis
an abnormal respiratory condition characterized by collapsed, shrunken deflated section of alveoli
A defect or sac formed by dilation in artery wall due to atherosclerosis, trauma, o congenital defect.
aneurysm
What are thiazides, ACE inhibitors
antihypertensives
Blowing, swooshing sound heard through a stethoscope when an artery is partially occluded.
bruit
When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use? A) Use the blunt end of the reflex hammer to strike a smaller area. B) Strike the area slowly and methodically. C) Hold the reflex hammer between the thumb and index finger. D) Percuss the area of the tendon to be struck for the reflex.
c
When describing fluid exchange and the capillaries, the instructor explains which mechanism as the most likely cause if oxygen, water, and nutrients are having difficulty entering the interstitial fluid? A) Osmotic pressure B) Gravitational flow C) Hydrostatic force D) Diastolic pressure
c
Which of the following would the nurse expect to assess if a client has a lesion of the sympathetic nervous system? A) Bilateral dilated pupils B) Unilateral dilated pupil C) Argyll-Robertson pupils D) Constricted pupil unresponsive to light
d
Where is the parietal pleura?
lines the insides of the chest wall and diaphragm.
Where is the visceral pleura?
lines the outside of the lungs, dipping down into the fissures
Bronchovesicular
the normal breath sound heard over major bronchi, characterized by moderate pitch and an equal duration of inspiration and expiration
Vesicular
the soft, low-pitched, normal breath sounds heard over peripheral lung fields
Consolidation
the solidification of portions of lung tissue as it fills up with infectious exudate, as in pneumonia
Stridor is a high-pitched, inspiratory crowing sound commonly associated with: A) upper airway obstruction. B) atelectasis. C) congestive heart failure. D) pneumothorax.
upper airway obstruction
The absence of bowel sounds is established after listening for how long?
5 full minutes.
How many degrees is the normal costal angle?
90
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. What does this finding indicate?
Blood flow turbulence
PAD ulcer appearance
Bony prominences gangrene severe pain decrease or absent pulse
Auscultating the abdomen is begun in the right lower quadrant (RLQ) because....
Bowel sounds are always normally present here.
What are the three types of normal breath sounds?
Bronchial, bronchovesicular, vesicular
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex
Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position? A) Upper lobes—lateral chest B) Upper lobes—posterior chest C) Lower lobes—posterior chest D) Lower lobes—anterior chest
Lower lobes—posterior chest
Increased tactile fremitus would be evident in an individual who has which of the following conditions? A) Emphysema B) Pneumonia C) Crepitus D) Pneumothorax
Pneumonia
The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?
Tetralogy of Fallot
Which of the following voice sounds would be a normal finding? A) The voice transmission is distinct and sounds close to the ear. B) The "eeeee" sound is clear and sounds like "eeeee". C) The whispered sound is transmitted clearly. D) Whispered "1-2-3" is audible and distinct.
The "eeeee" sound is clear and sounds like "eeeee".
Whispered pectoriloquy
a whispered phrase head through the stethoscope that sounds faint and inaudible over normal lung tissue
Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
b
Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy? A) Inability to detect sharp and dull stimuli B) Inability to wrinkle the forehead C) Closure of the affected eye from swelling D) Muscle spasm of the lower face on the affected side
b
Which of the following would a nurse suspect if dullness is percussed at the last interspace at the anterior axillary line on deep inspiration? A) Hepatomegaly B) Splenomegaly C) Abdominal mass D) Intestinal air
b
Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? A) This indicates the heart is working efficiently. B) Increased urination at rest may indicate heart failure. C) The client has decreased performance levels of activities of daily living. D) The client most likely sleeps without a pillow at night.
b
While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include? A) Circumduction B) Flexion C) Abduction D) Internal rotation
b
Loud, gurgling bowel sounds signaling increased motility or hyper-peristalsis; occurs with early bowel obstruction, gastroenteritis, diarrhea.
borborygmi
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? A) This is a normal response by the heart's conduction system. B) This is the body's response to an increase in cardiac output. C) The heart is attempting to increase cardiac output. D) The heart is responding to increased renal perfusion.
c
Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A) 2/5 B) 3/5 C) 4/5 D) 5/5
c
Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion? A) Phalen's test B) Tinel's test C) Ballottement test D) Lasegue's test
c
The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
c
Arteiosclerosis
calcification of arterial walls
percutaneous transluminal angioplasty
catheter is inserted through femoral artery, inflates and dialates the vessel by cracking the confining artherosclerotic intimal shell
The thoracic cage is defined by all of the following except the: A) sternum. B) ribs. C) costochondral junction. D) diaphragm.
costochondral junction.
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? A) Vital signs B) Neurologic system C) Cardiac function D) Coordination
d
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization? A) P wave B) QRS complex C) ST segment D) T wave
d
A group of students is reviewing information about the lymph nodes of the lower extremity and the areas drained by them. The students demonstrate the need for additional teaching when they identify which area as being drained by the superficial inguinal nodes? A) Legs B) External genitalia C) Upper abdomen D) Buttocks
d
A nurse assesses a client's jugular venous pulse to gather information about which of the following? A) Left arterial pressure. B) Left ventricular diastolic filling. C) Right ventricular pressure. D) Hemodynamics of the right side of the heart.
d
A nurse is demonstrating the technique for auscultating heart sounds. Which of the following would be most important for the nurse to emphasize? A) Start at the apex. B) Listen over each of the heart chambers. C) Use both the bell and diaphragm. D) Cover the entire precordium.
d
A nurse is determining a client's ankle-brachial index. Which result would indicate to the nurse that the client if free of arterial occlusion? A) 0.5 B) 0.7 C) 0.9 D) 1.1
d
A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test? A) Remote memory B) Sensation C) Mental status exam D) Balance
d
A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following? A) Normoactive B) Hyperactive C) Hypoactive D) Absent
d
When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency? A) Participation in daily exercise B) A family history of arterial insufficiency C) Intake of 2 beers per week D) Cigarette smoking
d
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A) Stationary soft palate on phonation B) Deviation of uvula when client says "ah" C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally
d
Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance.
d
Which of the following would be most appropriate to do when 45-degree flexion of the cervical spine is noted in an adolescent client? A) Assess the thoracic and lumbar spine. B) Palpate the spinous processes. C) Perform the Lasegue test. D) Continue the exam because this curve is normal.
d
Which of the following would lead the nurse to suspect meningeal irritation? A) Hips and knees remain relaxed and motionless when neck is flexed B) Reports of decreased pain with flexion of the hips and knees C) Discomfort behind the knee with full extension of the leg D) Pain and flexion of the hips and knees with neck flexion
d
Which technique would be most appropriate to use when examining the jugular venous pulse? A) Perform the exam with the client in a supine position. B) Have the client look straight ahead with chin slightly lifted. C) Have the client sit up at a 90-degree angle. D) Inspect the suprasternal notch or around the clavicles.
d
Dyspnea
difficult, labored breathing
Wheeze
high-pitched, musical, squeaking adventitious lung sound
An increase in the transverse diameter of the chest cage in a pregnant female is due to a(n): A) compensatory increase in respiratory parenchyma. B) increase in estrogen. C) increase in surfactant. D) increase in tidal volume.
increase in estrogen.
Hyperventilation
increased rate and depth of breathing
Bronchitis
inflammation of the bronchi with partial obstruction of bronchi due to excessive mucus secretion
PAD - Asprin and Clopidogrel (Plavix)
inhibit platelet aggregation
contrat phlebography (venography)
measures capacity of the veins
Cilia
millions of hairlike cells lining the tracheobronchial tree
Bronchiole
one of the smaller respiratory passageways into which the segmental bronchi divide
PVD - peripheral vascular disease
problems altering blood flow to veins and arteries
PAD - peripheral artery disease
problems only with arterial flow
Tachypnea
rapid, shallow breathing, > 20 breaths per minute
A ______ abdomen caves in.
scaphoid
Tenderness during abdominal palpation is expected when palpating the _______.
sigmoid colon
Bradypnea
slow breathing, <12 breaths per minute
Intercostal space
space between the ribs
Treatment for PAD
stop smoking encourage walking to point of pain foot care diet high in fruit, vegies, low in cholesterol, saturated fat and salt decrease sitting and standing endartectomy pheripherial artery bypass PCI (stents, plaque removal, cryoplasty) amputation Risk factor modification
Percussion
striking over the chest wall with short, sharp blows of the fingers to determine the size and density of underlying organs
Paroxysmal nocturnal dyspnea
sudden awakening from sleeping with shortness of breath.
Manifestations of venous insuff.
superficial venous reflux vericous veins swollen legs skin changes skin ulcers
Nursing management after endovascular repair
supine for 6 hours VS and doppler assessment every 15 min access site ( femoral or illiac artery) check temp every 4 hours.
bypass graft
synthetic graft or autogenous vein used to bypass occlusion.
Emphysema
the chronic obstructive pulmonary disease characterized by enlargement of alveoli distal to terminal bronchioles
Surfactant
the complex lipid substance needed for sustained inflation of the air sacs
Bronchophony
the spoken voice sound heard through the stethoscope, which sounds soft, muffles, and indistinct over normal lung tissue
Egophony
the voice sound of "eeeeeeee" heard through the stethoscope
The function of the trachea and bronchi is to: A) transport gases between the environment and the lung parenchyma. B) condense inspired air for better gas exchange. C) moisturize air for optimum respiration. D) increase air turbulence and velocity for maximum gas transport.
transport gases between the environment and the lung parenchyma.
High-pitched, musical, drum-like percussion heard when percussing over the stomach and intestine.
tympany
How to Dx PAD
Doppler Segmental blood pressures angiography
True or False: Statins are used with VD
False
Apnea
cessation of breathing
A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. "I'll be sleeping great, and then I wake up and feel like I can't get my breath." Which is the best response by the nurse?
"Do you have any history of problems with your heart?"
what do thiazides, ACE inhibitors treat
PAD
palpable with thick bronchial secretions.
Rhoncal fremitus
Hypercapnia
(hypercarbia) increased levels of carbon dioxide in the blood
Hypoxemia
decreased level of oxygen in the blood
What is the normal stimulus to breathe?
Increase in carbon dioxide in the blood
Right upper quadrant tenderness may indicate pathology in what organs?
Liver, pancreas, or ascending colon.
Male (58 yrs)-Slightly underweight, weathered and dehydrated skin, smoker with history of uncontrolled hypertension. Presents to the ER in the middle of the night complaining that whenever he lays down his legs start to hurt so much that he cannot stand it and is unable to sleep. He indicates that sometimes after a busy day he will lay down and his legs will ache or spasm, after getting up a few times in the night and walking around, he notices that this subsides. However tonight he states that the leg pain is where it usually is, in his calves and feet, but it is more severe than usual, and he wants pain medication, so he can rest at night and go to work during the day. Upon removing his shoes and socks and elevating his feet, the nurse assesses BLE and notes very weak bilat. pedal pulses and delayed capillary refill. Which type of circulatory condition does he most likely have? What is the medical term for the pain the patient is complaining about? What can we teach her about managing the pain?
Peripheral Arterial disease Intermittent Claudication, pg 506 in Text book Quit Smoking Reduce Elevation time of legs Continue being active for smaller amounts of time; stop when pain occurs. Manage BP Use of Pain Medication as prescribed
Male (51 yrs)-Obese, complaining of pain and swelling in lower legs. Indicates that he has had swelling from time to time in the lower ext., but the swelling and pain dissipate after he elevates the legs for a "few hours". But now he notices the pain is increasing and the swelling returns more quickly when his legs are down. He indicates that he wants something for the pain because he has to work long hours standing in one place on the assembly line. Which type of circulatory condition does he most likely have? What can we teach her about managing the swelling and pain?
Peripheral Venous disease Elevate legs often compression stockings, exercise, weight loss, consider job change, or ability to sit down, move around more.
What are the three factors that affect normal intensity of tactile fremitus?
Relative location of bronchi to the chest wall Thickness of the chest wall Pitch and intensity of voice
The direction of blood flow through the heart is best described by which of these?
Right atrium --> right ventricle --> pulmonary artery --> lungs --> pulmonary vein --> left atrium --> left ventricle
What component of the conduction system is referred to as the pacemaker of the heart?
Sinoatrial (SA) Node
Manifestations for VD
Skin changes (brown color, leathery, thin, shiny) edema eczema higher skin temperature around ankle thick, fibrous tissue
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
What are the four function of the respiratory system?
Supply oxygen, remove carbon dioxide, maintain homeostasis of arterial blood, and maintain heat exchange
True or False: Antiplatelets (ASA,Plavix) are used with PAD
True
The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage?
The jugular veins will remain elevated as long as pressure on the abdomen is maintained
Which of these statements describes the closure of the valves in a normal cardiac cycle?
The tricuspid valve closes slightly later than the mitral valve
Crackles
(rales) abnormal, discontinuous, adventitious lung sounds heard on inspiration.
occurs when anything obstructs transmission of vibrations (e.g., obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema)
.Decreased fremitus
When comparing the anteroposterior diameter of the chest with the transverse diameter, what is the expected ratio?
1:2 to 5:7
What is the normal range of liver span in the right clavicular line in the adult?
2 to 6 cm
How many lobes do the right and left lungs have?
3 on right and 2 on left
A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying it as which of the following? A) Myocardium B) Epicardium C) Endocardium D) Pericardium
A) Myocardium
While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following? A) Pericardial friction rub B) Midsystolic click C) Summation gallop D) Aortic ejection click
A) Pericardial friction rub
Pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder. What does this indicate?
A positive Murphy's sign
The nurse is preparing to teach a class on cardiovascular assessment. When explaining a thrill, what should the nurse include in the teaching?
A vibration that is palpable
Pleural effusion
abnormal fluid between the layers of the pleura
manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second rib
Angle of Louis
Which sequence does the electrical stimulus of the cardiac cycle follow?
AV node --> SA node --> bundle of His --> bundle branches
functional units of the lung; the thin-walled chambers surrounded by networks of capillaries that are the site of respiratory exchange of carbon dioxide and oxygen
Alveoli
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
The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?
Blacks
When listening to heart sounds, which valve closures are heard best at the base of the heart?
Aortic and pulmonic
Auscultation of the abdomen may reveal bruits of which arteries?
Aortic, renal, iliac, and femoral.
Female (72 yrs)-Slightly overweight, presents with deep, dime sized open area on the Rt. lateral malleolus. Her BLE skin is shiny, without hair noted below the knee. Which type of circulatory ulcer does she most likely have?
Arterial Ulcer
A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. Based on these findings and the patient's history, the nurse should recognize this extra heart sound is most likely what?
Atrial gallop
After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following? A) Chordae tendineae B) Ventricles C) Semilunar valves D) Precordium
B) Ventricles
A patient is coughing up yellow or green sputum. The color of the sputum is indicative of what condition?
Bacterial infection
In assessing for an S4 heart sound, what part of the stethoscope should the nurse use and in what location?
Bell of the stethoscope at the apex with the patient in the left lateral position
A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following? A) Bundle of His B) Purkinje fibers C) Pacemaker D) Conduction system
C) Pacemaker
Describe hyperactive bowel sounds.
High-pitched, rushing, tinkling noises.
What is the best description of the S1 heart sound?
Coincides with the carotid artery pulse
A patient is coughing up white or clear mucoid. The characteristic of the sputum is indicative of what conditions?
Colds, bronchitis, or viral infections
Treatment for VD
Compression therapu (teds, SCDs, ace wraps) dressing changes ( wet to dry) diet high in protein, calories, vit A and C, iron, Zinc antibiotics with infections skin grafts foot care avoid sitting and stganding for long periods ELEVATE legs to reduce edema encourage walking vein stripping vein transplant
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What should the nurse do?
Document this as a normal finding
PAD - Pentoxifylline (Trental)
Decrease blood viscosity and increase RBC flexability
PAD - Statins
Decrease plaque formation
Inspiration is primarily facilitated by which of the following muscles? A) Diaphragm and abdominus rectus B) Trapezia and sternomastoids C) Internal intercostals and abdominal D) Diaphragm and intercostals
Diaphragm and intercostals
During the precordial assessment of a patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. What does this finding indicate?
Displacement of the heart from elevation of the diaphragm
Medication for VD
Diuretics anticoagulant (Heparin, coumadin for extended therapy)
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. What does this finding indicate?
Elevated pressure r/t heart failure
During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. What does this finding most likely indicate?
Enlargement of the right ventricle
What are 5 factors that can cause extraneous noise during auscultation?
Examiner's breathing on stethoscope tubing Stethoscope tubing bumping together Patient shivering Patient's chest hair Rustling of paper gown or paper drapes
When performing a cardiovascular assessment, what should the nurse understand about an S4 heart sound?
Heard at the end of the ventricular diastole
During a cardiac assessment on a 38-year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?
Heart failure
What the normal percussion sounds in adults and children?
In adults it is resonant, and in children it is hyperresonant
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by the expected hemodynamic changes r/t age?
Increase in systolic blood pressure
The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. What does the nurse suspect?
Inflammation of the precordium
What is the seqence of events used during an examination of the abdomen?
Inpection, asculatation, percussion, palpation
What is the normal splitting of the S2 is associated with?
Inspiration
What a manefestations for PAD
Intermittent claudication parethesia changes oh physical appearance ( thin, shiny and taut skin, hair loss) increased pain with ELEVATION diminished pulses pallor
A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. What do these findings most likely indicate?
Mitral regurgitation
Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?
Murmur at the second left intercostal space when supine
The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. How should the nurse interpret this finding?
Normal for this age
Chronic obstructive breathing
Normal inspiration and prolonged expiration to overcome increased airway resistance.
forward protrusion of the sternum with ribs sloping back at either side.
Pectus carinatum
sunken sternum and adjacent cartilages
Pectus excavatum
What is the sac that surrounds and protects the heart is called?
Pericardium
A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved? A) Gall bladder B) Kidneys C) Stomach D) Pancreas
a
The nurse observes rebound tenderness in the abdomen of a patient. What condition does this finding indicate?
Rebound tenderness is assessed when the patient reports abdominal pain. Rebound tenderness is a reliable sign of peritoneal inflammation caused by appendicitis.
The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?
Studies show that percussed cardiac border do not correlate well with the true cardiac border
Medications for PAD
Statins (lovastatin) antihypertensives (thiazides, ACE inhibitors) Antiplatelets (ASA,Plavix)
A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source? A) Cardiac B) Gastrointestinal C) Musculoskeletal D) Pulmonary
a
When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?
While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it
A group of students is reviewing information about the different types of murmurs. Which of the following would they identify as examples of midsystolic murmurs? A) Innocent B) Mitral regurgitation C) Mitral stenosis D) Ventricular septal defect
a
A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following would the nurse do next? A) Document this finding as normal. B) Recheck in 5 minutes after elevating the arm. C) Reassess after applying warm compresses. D) Refer the client for medical follow-up.
a
A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following? A) It is a normal-sized liver. B) The liver is larger than normal. C) The liver is smaller than normal. D) The liver has atrophied.
a
A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do? A) Lock the fingers together and pull against each other. B) Clench the jaw tightly. C) Squeeze a thigh with the opposite hand. D) Stretch the arms over head.
a
A nurse obtains the following information: right arm brachial pressure, 160; left arm brachial pressure, 150; right ankle pressure, 80; left ankle pressure, 94. The nurse determines that the right ankle-brachial index would be which of the following? A) 0.50 B) 0.53 C) 0.59 D) 0.63
a
Abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer, or portal hypertension.
ascites
An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect? A) Arterial insufficiency B) Musculoskeletal weakness C) Venous insufficiency D) Neurologic impairment
a
Assessment of a client's lower extremities reveals unilateral edema of the right extremity. Which of the following would be most appropriate for the nurse to do next? A) Compare measurements of both extremities. B) Perform the Allen's test C) Check for bilateral varicosities. D) Palpate the femoral pulses.
a
During a health visit, a client says, "I know that arteries and veins are blood vessels, but what's the difference?" Which of the following would the nurse include in the response? A) Arteries have thicker walls than veins. B) Arteries carry 70% of the body's blood volume. C) Arteries have a lower pressure than veins. D) Arteries carry waste from the tissues.
a
The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?
The atria contract toward the end of diastole and push the remaining blood into the ventricles
During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect? A) Gouty arthritis B) Rheumatoid arthritis C) Degenerative joint disease D) Plantar fasciitis
a
On examination, the nurse would expect what finding if a client is in right-sided failure? A) Increased jugular venous pressure B) Decreased right-sided volume C) Decreased central venous pressure D) Decreased stroke volume
a
While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?
These findings can all be normal in a child
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
This decline in blood pressure is the result of peripheral vasodilation and is an expected change
Fremitus
a palpable vibration from the spoken voice felt over the chest wall
While assessing a 35-year-old patient, the nurse hears a vascular sound between the xiphoid process and the umbilicus. What can the nurse presume from the sound?
Vascular sounds are also called bruits.
PAD - Cilostazol (pletal)
Vasodilation, increase walking distance
Which can be noted through inspection of a patients abdomen?
Venous pattern, peristaltic waves, and abdominal contour.
Female (68 yrs)-Obese, hx of vein stripping, starting bilat. varicose veins in calf area in her 50's d/t prolonged hours of standing while working as a teller in the local grocery store. Presents with non-healing wound, on the Lt. medial lower calf muscle region. Which type of circulatory ulcer does she most likely have?
Venous stasis Ulcer
During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. What does this finding indicate?
Volume overload, as in heart failure
During cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. What should the nurse do to further assess this sound?
Watch the patient's respirations while listening for the effect on the sound
Orthopnea
ability to breathe easily only in an upright position
A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client? A) It filters harmful substances from the body. B) It produces protective antibodies. C) It manufactures T lymphocytes. D) It drains capillary blood from the circulation.
a
A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse interprets this as which of the following? A) Positive Rovsing's sign B) Psoas sign C) Obturator sign D) Positive skin hypersensitivity test
a
A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating the cycle. The most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, and increased intracranial pressure. Occurs normally in infants and aging persons during sleep.
`Cheyne-Stokes respiration
The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate? A) Palpate each artery individually to compare B) Palpate the arteries before auscultating them C) Use the diaphragm of the stethoscope D) Ask the client to breathe in and out deeply
a
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following? A) Venous insufficiency B) Stasis ulceration C) Arterial occlusion D) Dependent edema
a
When assessing a client for possible varicose veins, which of the following would the nurse do? A) Have the client stand for the exam B) Tell the client to raise his or her leg C) Dorsiflex the client's foot D) Obtain the ankle-brachial index
a
When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following? A) Pronation B) Flexion C) Rotation D) Supination
a
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole? A) S1 B) S2 C) S3 D) S4
a
When explaining how the nurse would test graphesthesia, which of the following would the nurse include? A) Client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object B) The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time. C) The nurse will simultaneously touch the client in the same area on both sides of the body and the client will identify where the touch occurred. D) The nurse will briefly touch the client and the client will need to identify where the touch occurred.
a
When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A) Vitamin supplement with iron B) Nonsteroidal anti-inflammatory drug C) Antidepressant D) Hormone replacement
a
When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect? A) Meningitis B) Cervical strain C) Compression fracture D) Cervical disc degeneration
a
Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes
a
Which strategy by the nurse would best facilitate palpation of a ticklish client's abdomen? A) Have client place hand on the abdomen with the nurse's hand on top. B) Press very firmly on the abdomen so the tickle sensation is absent. C) Distract the client with conversation about family while palpating the abdomen. D) Place a small amount of lubricant on the skin so the nurse's fingers will slide more easily.
a
Which test would be most appropriate for the nurse to perform when a client complains of low back pain? A) Lasegue test B) Muscle leg strength C) Lateral bending of cervical spine D) Internal rotation of the shoulders
a
A nurse is preparing to perform a complete neurologic exam. Place the assessments in the most appropriate sequence for the nurse to perform them. A) Cranial nerves B) Reflexes C) Mental Status D) Motor/cerebellar function E) Sensory system
a b c d e
An instructor is explaining the various causes associated with abdominal distention. Which of the following would the instructor include? Select all that apply. A) Fat B) Stool C) Gas D) Hernia E) Fibroid tumors
a b c e
When reviewing the neural pathways, a group of students identify which of the following as sensations that travel via the spinothalamic tract. Select all that apply. A) Pain B) Temperature C) Position D) Vibration E) Light touch
a b e
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. A) Flexion B) Abduction C) Extension D) Rotation E) Supination F) Circumduction
a c e
Friction rub
a coarse, grating, adventitious lung sound heard when the pleurae are inflamed
Chronic Obstructive Pulmonary Disease (COPD)
a functional category of abnormal respiratory conditions characterized by airflow obstruction (emphysema, chronic bronchitis)
Rhonchi
low-pitched, musical, snoring, adventitious lung sound caused by airflow obstruction from secretions
A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation? A) Dull B) Steady C) Cramping D) Burning
b
A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? A) Abdominal respiratory movements B) Visible peristaltic waves C) Symmetric appearance D) No bulging with head raising
b
A nurse is having difficulty determining a client's heart sounds, specifically S1 and S2. Which of the following would be appropriate for the nurse to do? A) Use the bell of the stethoscope to help distinguish the sounds B) Palpate the carotid pulse while auscultating the heart C) Determine the pulse deficit D) Palpate the apical impulse
b
A nurse is having difficulty palpating the femoral pulse on an adult client. Which of the following would be most appropriate for the nurse to do? A) Ask another nurse to assess the pulse. B) Listen for femoral bruits. C) Perform the Allen's test. D) Assess the popliteal pulse.
b
A nurse is preparing a presentation for a local community group about coronary artery disease and culture. Which information would the nurse include? A) Caucasians take higher lifestyle risks than African Americans. B) Hypertension is more prevalent in African Americans. C) Hypertension is seen more in white women than in African-American women. D) Hispanic Americans have a higher rate of coronary artery disease than white Americans.
b
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do? A) Use a Snellen chart to test visual acuity. B) Ask a client to identify scents. C) Test extraocular eye movements. D) Perform the Weber test.
b
A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex? A) Brachioradialis B) Triceps C) Biceps D) Achilles
b
A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position? A) Supine with head of bed elevated 30 degrees B) Leaning forward while in a sitting position C) Flat, left lateral D) Sitting upright in a straight back chair
b
After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A) Compact bone B) Red marrow C) Yellow marrow D) Spongy bone
b
After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb's point? A) Fifth intercostal space near the left midclavicular line B) Third to fifth intercostal space at the left sternal border C) Second intercostal space at the right sternal border D) Second or third intercostal space at the left sternal border
b
An instructor is observing a student assess a client's capillary refill. Which action by the student indicates the proper technique? A) Student gently compresses the wrist area on the side of the thumb B) Student compresses the client's nailbed until it blanches C) Student applies firm pressure to the hand, noting any indentation D) Student asks client to turn hands slowly over and back
b
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
b
The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation. A) Weight evenly distributed B) Shuffling of feet C) Stands on heels and toes D) Arms swinging in opposition
b
The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate? A) "I'm going to examine the area where you're having pain first to get a better picture of what's going on." B) "Before I get ready to examine the painful area, I will let you know in plenty of time." C) "You don't need to worry about anything. I will make sure to be very gentle during the exam." D) "Since you're having pain in a certain area, I won't have to do a very thorough exam there."
b
The nurse is preparing to assess the size of the aorta. The nurse would palpate at which location? A) Midline at the umbilicus B) Deep epigastrium to the left of midline C) Slightly above the suprapubic area D) Between the umbilicus and the symphysis pubis
b
When asked to touch the ear to the shoulder, a client reports pain. Which of the following would the nurse do next? A) Perform muscle strength against resistance. B) Refer the client for further evaluation. C) Flex and then hyperextend the neck. D) Palpate the paravertebral muscles for pain.
b
When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following? A) Decreased cardiac output B) Increased central venous pressure C) A narrowed vessel D) Right ventricular failure
b
When describing the major arteries of the arms and legs, which of the following would the instructor identify as the major supplier of blood to the arms? A) Radial artery B) Brachial artery C) Femoral artery D) Ulnar artery
b
When documenting the findings of a neurologic assessment, which of the following would be most important? A) Verify the data before documenting. B) Describe the client's response. C) Label the client's behavior. D) Record objective data primarily.
b
When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? A) 42-year-old Caucasian woman who smokes B) 68-year-old African American with hypertension C) 55-year-old Caucasian male who has a two beers a week D) 35-year-old African American who has sleep apnea
b
When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following? A) Hallus valgus B) Pes varus C) Verruca vulgaris D) Pes cavus
b
When measuring abdominal girth in a client with ascites, the nurse would place the client in which position? A) Sitting B) Standing C) Supine D) Prone
b
When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first? A) Check for evidence of fever and chills B) Ensure no injury to the cervical spine C) Position the client prone D) Check for a Babinski reflex
b
When testing muscle strength, a client has difficulty moving each extremity against resistance. Which of the following would the nurse do next? A) Move the part passively through its range of motion. B) Ask the client to move the part against gravity. C) Inspect by touch for a palpable contraction of the muscle. D) Compare bilateral findings.
b
Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency? A) Split B) Diminished C) Accentuated D) Varying
b
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. A) Avoid eating dark chocolate. B) Eat foods low in sodium. C) Walk for at least 30 minutes/day. D) Limit alcohol intake to 3 drinks per day. E) Use relaxation techniques to manage stress.
b c e
While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply. A) Irregular border B) Deep C) Circular in shape D) Moderate leg edema E) Client report of severe pain
b c e
A nurse is describing viscera to a group of nursing students in the clinical area, differentiating solid viscera from hollow viscera. Which of the following would the nurse describe as hollow viscera? Select all that apply. A) Liver B) Stomach C) Pancreas D) Gallbladder E) Small intestine F) Urinary bladder
b d e f
A client is diagnosed with osteomalacia. Which of the following would a nurse include in the client's teaching plan? A) Decreasing purine intake can reduce the risk of osteomalacia. B) An increased amount of vitamin C intake is recommended. C) At least 20 minutes of sunlight each day is recommended D) Reduce the amount of protein intake.
c
A female client tells the nurse that she has been diagnosed with systemic lupus erythematosus. The nurse would assess the client for which common complication? A) Diabetes mellitus B) Urinary tract infection C) Osteoporosis D) Early menopause
c
A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A) Palpate, percuss, inspect, auscultate B) Auscultate, inspect, palpate, percuss C) Inspect, auscultate, percuss, palpate D) Percuss, inspect, auscultate, palpate
c
A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant? A) Gallbladder B) Liver C) Spleen D) Head of pancreas
c
A group of students is reviewing information related to the major bones of the skeleton. The students demonstrate understanding of the material when they identify which of the following as part of the axial skeleton? A) Humerus B) Femur C) Vertebral column D) Carpals
c
A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next? A) Ask the client about any recent ear and throat infections. B) Carefully assess the cervical lymph nodes for enlargement. C) Examine the lower arm and hand for infection sites. D) Assess both legs for Homans' sign.
c
A nurse auscultates a client's hear rate and rhythm and finds the rhythm to be irregular. Which of the following would the nurse do next? A) Inspect for a lift B) Palpate for a thrill C) Auscultate for pulse rate deficit D) Listen for a ventricular gallop
c
A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following? A) Hypothyroidism B) Fever C) Mitral stenosis D) Heart murmur
c
A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor? A) Small-boned, thin frame B) Personal history of fractures C) Low estrogen levels D) Age
c
A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? A) Flexion of 80 degrees B) Lateral bending of 35 degrees C) Hyperextension of 20 degrees D) Rotation of 30 degrees
c
A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next? A) Refer the client for medical follow-up. B) Document the finding. C) Palpate the brachial pulse. D) Auscultate the apical pulse.
c
A nurse prepares to perform the manual compression test on a client with which of the following? A) Venous ulcer B) Arterial occlusion C) Varicose veins D) Lymphedema
c
A nurse suspects intra-abdominal bleeding in a client who was involved in a motor vehicle accident 3 days ago. Which finding would the nurse most likely have noted? A) Tenderness on palpation B) Diastasis recti C) Cullen's sign D) Tympany on percussion
c
After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data? A) Denies pain in hips or legs B) Complains of burning in lower back C) Neck rotation limited to 50 degrees D) History of osteoporosis
c
After teaching a group of students about the brain and spinal cord, the instructor determines that the students demonstrate the need for additional teaching when they identify which of the following as being controlled by the brainstem? A) Respiratory function B) Heart rate C) Equilibrium D) Reflex actions
c
After teaching a group of students about the great vessels, the instructor determines that the students need additional teaching when they identify which of the following as a great vessel? A) Aorta B) Pulmonary vein C) Carotid artery D) Inferior vena cava
c
Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect? A) Ascites B) Appendicitis C) Cholecystitis D) Splenomegaly
c
The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant
c
The nurse is percussing a client's' liver and is assessing liver descent. The nurse would have the client do which of the following? A) Cough forcefully B) Hold his or her breath C) Breathe deeply D) Perform the Valsalva maneuver
c
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next? A) Document "absence of dorsalis pedis pulse." B) Auscultate the anatomic area with a stethoscope. C) Use Doppler ultrasonography to locate the pulse. D) Ask another nurse to assess the pulse.
c
To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do? A) Encourage the client to hold his or her breath. B) Cover the client in a warm blanket. C) Place a pillow under both of the client's knees. D) Assure the client that painful areas will not be examined.
c
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? A) Crescendo B) Decrescendo C) Crescendo-decrescendo D) Plateau
c
When examining a client with a rotator cuff tear, which of the following would the nurse expect to find? A) Limitation of all shoulder motion B) Chronic pain C) Limited abduction D) Sharp catches of pain with movement
c
When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following? A) Flat B) Rounded C) Scaphoid D) Protuberant
c
When reviewing the adult circulation, the nurse understands that which mechanism primarily aids in returning blood to the heart?? A) Pressure gradients B) Gravitational flow C) Muscular contractions D) Heart muscle contraction
c
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve? A) Ask client to differentiate sharp and dull sensations on client's face. B) Have the client smile, frown and wrinkle the forehead. C) Palpates temporal and masseter muscles while client clenches teeth. D) Assess dilatation of pupils with direct light.
c
Which of the following would be most appropriate when the nurse notes limitation in active range of motion of a client's right shoulder? A) Test muscle strength. B) Perform passive range of motion test. C) Measure range of motion with a goniometer. D) Ask the client which is the dominant side.
c
Which of the following would the nurse expect to find when examining a client with a herniated lumbar disc? A) Rounded thoracic convexity B) Lumbar lordosis C) Flattened lumbar curve D) Lateral curvature of the spine
c
Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? A) Inability to hear high-pitched sounds B) Loss of tactile sensation C) Difficulty speaking D) Blurred vision
c
Which question would be most important to ask obtaining the nursing health history of a male client with extensive peripheral vascular disease? A) "Do your parents have trouble with circulation?" B) "When was your last prostate exam for cancer?" C) "Have you experienced a change in your usual sexual activity?" D) "Have you had an electrocardiogram recently?"
c
While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following? A) Hernia B) Malignancy C) Infection D) Aneurysm
c
When a nursing instructor is describing the peripheral nervous system to a group of students, the instructor would explain that there are how many pairs of spinal nerves? A) 8 B) 11 C) 24 D) 31
d
Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions? A) Shifting dullness B) Fluid wave C) Abdominal x-ray D) Ultrasound
d
During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate? A) Refer the client for medical follow-up. B) Evaluate further for a problem with the spleen. C) Assess urinary output. D) Document the position of the liver.
d
During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following? A) Spastic hemiparesis B) Parkinsonian gait C) Scissors gait D) Cerebellar ataxia
d
During the history, a young adult woman tells the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate? A) "Increase the amount of non-weight-bearing physical activity that you do." B) "Keep your calcium intake around 800 milligrams each day." C) "Avoid being out in the sun for long periods of time." D) "Try to avoid drinking too much coffee or other caffeinated fluids."
d
The nurse demonstrates the correct technique for assessing the psoas sign by which action? A) Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing B) Tapping fingerpads over the client's abdominal wall, feeling for a floating mass C) Flexing the client's right hip and knee, rotating the hip internally and externally D) Flexing the client's right hip, applying downward pressure on the right thigh
d
The nurse determines that a client's edema of the lower extremities is most likely due to lymphedema based on which of the following? A) Pitting edema B) Ulceration of the skin C) Areas of pigmentation D) Bilaterally present
d
The nurse elicits a positive Homans' sign in a client's right leg. Which of the following might the nurse suspect? A) Arterial occlusion B) Venous insufficiency C) Varicose veins D) Thrombophlebitis
d
The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve? A) III B) V C) VII D) XI
d
The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action? A) Isometric contraction B) Closure of the semilunar valves C) Beginning of diastole D) Closure of the atrioventricular valves
d
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location? A) Second intercostal space, left sternal border B) Third intercostal space, left axillary line C) Fourth intercostal space, left sternal border D) Fifth intercostal space, left midclavicular line
d
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? A) Romberg B) Tandem walking C) Gait D) Hop on one foot
d
The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate? A) At the anterior area of the sternoclavicular joint B) At the posterior temporomandibular joint C) At the olecranon process of the elbow D) At the back of the wrist and extended thumb
d
The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate? A) Just behind the knee B) At the top of the foot C) In the groin area D) Behind the ankle
d
The nurse measures the circumference of a client's arms because of lymphedema in the right arm. The nurse obtains a difference of 6 cm between the right and left arms. The nurse would document this finding as which state of lymphedema? A) 0 B) I C) II D) III
d
Dead space
passageways that transport air but are not available for gaseous exchange (trachea, bronchi)
continuous wave doppler ultrasound
detects blood flow combined with ankle pressure - helps characterize the nature of PVD
The gradual loss of intraalveolar septa and a decreased number of alveoli in the lungs of the elderly cause: A) hyperventilation. B) spontaneous atelectasis. C) decreased surface area for gas exchange. D) decreased dead space.
decreased surface area for gas exchange.
While assessing a 4-year-old patient, the nurse observes the abdomen of the child has a scaphoid shape. What is the possible cause of the shape?
dehydration
Percussion of the chest is: A) a useful technique for identifying small lesions in lung tissue. B) helpful only in identifying surface alterations of lung tissue. C) is not influenced by the overlying chest muscle and fat tissue. D) normal if a dull note is elicited.
helpful only in identifying surface alterations of lung tissue.
Atherosclerosis
lesions obstructing vessel lumen
VD ulcer appearance
located over ankles brown discoloration weeping, drainage normal skin temp edema aching pain normal pulses
Which soft, lobulated gland is located behind the stomach?
pancreas
Revascularization
procedure done if there are gangrenous lesions
A ______ abdomen can indicate abdominal distention and fluid retention.
protrubent
Patient is coughing up pink, frothy sputum. The characteristic of the sputum is indicative of what conditions?
pulmonary edema & some sympathomimetic medications have a side effect of this type of sputum.
A clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is: A) periodic breathing patterns. B) pursed-lip breathing. C) unequal chest expansion. D) hyperventilation.
pursed-lip breathing.
