NSG 200 Test 2 Study Questions

A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which question is the most logical for the nurse to ask?

"Do you have allergies?"

A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask for the symptom analysis?

"Do you have any symptoms such as nausea with this pain?"

A patient complains of pain in the calf when walking. Which question should the nurse ask for further data?

"Does the pain go away when you stop walking?"

A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document these findings?

"Enlarged tonsils 4+ with yellow exudate."

The nurse suspects that a female patient is having trouble with the thyroid when the patient answers yes to which question?

"Have you noticed a change in your level of energy?" Changes in thyroid function may cause symptoms of hyperactivity or fatigue.

What question does a nurse ask a patient with a history of pancreatitis who is complaining of abdominal pain?

"How severe is the pain on a scale of 0 to 10?"

Which question gives the nurse further information about the patient's complaint of chest pain?

"How would you describe the chest pain?"

A patient complains of chest pain. Which report made by a patient would suggest to the nurse that the chest pain is cardiac in origin?

"My chest feels really tight and heavy." Tightness, squeezing, or heaviness are classic descriptions of cardiac pain.

Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss?

"My primary hobby is carpentry work"

A 50-year-old patient asks how he can reduce his risk of colon cancer. What is the most appropriate response by the nurse?

"Regular exercise to reduce body fat helps prevent colon cancer."

A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information?

"What did the vomit look like?"

When a patient complains of chest pain, which question is pertinent to ask to gain additional data?

"What does the pain feel like?"

A patient reports that he has intermittent chest pain. Which is the most appropriate question to ask next?

"What other symptoms do you have when the chest pain occurs?" Complete a symptom analysis to learn more about the pain. Do not look for the cause of the pain until you know more about the pain.

During the history the patient indicates that her eyes have been red and itching. Which additional question does the nurse ask?

"do you have seasonal allergies?"

The nurse is palpating a patient's pericardium. What may be detected by palpating the pericardium?

A thrill A thrill is detected as a vibration sensation on the chest wall and may indicate a murmur.

In which patient would a pulsation within the epigastric area be considered a normal finding during inspection?

A very thin patient

What is the most accurate technique for detecting a venous thrombosis at the bedside?

Measure the thigh circumference to detect an increase from the baseline.

Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings?

Mr. P, whose blood pressure has been 110/78

The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated?

Pulmonic area

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding?

Rhonchi

The nurse is treating a patient for a nosebleed. The patient complains of frequent nosebleeds. What could be a possible cause of the nosebleeds?

Snorting cocaine Cocaine is an irritant to the nasal mucosa. Further assessment would be required to rule this out. Hypertension may be associated with nosebleeds.

Where does a nurse palpate to assess the posterior tibial pulse?

The inner aspect of the ankle below and slightly behind the medial malleolus

The nurse is assessing a patient's optic disc. What instrument would be best for this assessment?

The optic disc is viewed with an ophthalmoscope.

A patient is complaining of difficulty hearing. Which structure of the ear stimulates the acoustic nerve?

The ossicle Three tiny bones make up the ossicle. This structure transmits sound.

The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean?

The patient may have a pleural effusion. Fluid in the pleural space can be detected by noting a difference in diaphragmatic excursion.

What are the characteristics of lymph nodes in patients who have an acute infection?

They are enlarged and tender.

The nurse is assessing a patient's mandible. The area between the sternocleidomastoid muscles and the mandible is anatomically known as the:

anterior triangle. Anterior triangle is fairly well defined, especially on thin individuals.

The student nurse is studying the liver. The primary function of the liver is to:

metabolize nutrients.

The nurse should auscultate the abdomen for at least __ before documenting an absence of bowel sounds.

several minutes If no bowel sounds are heard after several minutes, an absence of bowel sounds can be documented.

The nurse is percussing the heart. Percussion of the heart could be performed to:

estimate the heart's size and borders. Estimating the heart's size and borders is not often performed when x-rays are available.

The nurse includes questions about chest pain as part of an abdominal history because myocardial pain can be:

perceived as esophageal and stomach pain. Patients may incorrectly assume that myocardial ischemic pain is caused by heartburn

The nurse is assessing a patient for confrontation. The confrontation test assesses:

peripheral vision. The examiner must have normal peripheral visual fields to do this.

A patient has 3+ pitting edema in her feet and ankles. The nurse suspects:

the patient has excess fluid in the interstitial space. Interstitial edema can manifest as pitting edema.

The nurse auscultates the abdomen to gain information regarding:

the peristaltic activity of the intestinal tract. Peristaltic activity produces bowel sounds.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of what?

*Muffled voice sounds and symmetric tactile fremitus *Symmetric chest *Resonant percussion tones *Expansion muffled voice sounds

A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the tongue. What additional data does the nurse specifically collect about this patient?

Alcohol and Tobacco use

Which patient has the greatest risk for hypertension?

An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner

Which technique is used for palpating lymph nodes?

Apply gentle pressure over the nodes with the pads of the fingers.

A patient reports leg and foot pain with activity that resolves with rest. With what type of problem is this consistent?

Arterial insufficiency Also ask the patient if the pain increases when the legs are elevated; this is another common finding.

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding?

Ask the patient to cough then repeat the auscultation.

The nurse is palpating a patient's chest wall. What can be accomplished with palpation of the chest?

Assessment of equal chest expansion Thoracic expansion is assessed easily.

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect?

Asthma Asthma impairs airway movement, which contributes to wheezes and decreased breath sounds.

While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss?

Audiometry test

A nurse performing an abdominal examination on a 37-year-old woman would document which finding as abnormal?

Bulges observed when coughing

How does the nurse assess a patient's consensual reaction?

By shining a light into the patient's right eye and observing the pupillary reaction of the left eye

The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding?

Chronic obstructive pulmonary disease The costal angle increases because of an increased AP diameter.

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color?

Clear

A patient describes a recent onset of frequent and severe unilateral headaches that last about 1 hour. Based on these symptoms, the nurse suspects which type of headache?

Cluster headaches

A nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate?

Decreased breath sounds on auscultation

Which technique does the nurse use to palpate a patient's abdomen?

Depresses the abdomen 1 cm for light palpation

How does a nurse determine jugular vein pulsations?

Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected?

Fever and tachypnea with crackles over the right lower lobe

The nurse assesses a pulse at 3+ amplitude. Which word best describes a pulse with 3+ amplitude?

Full volume 3+ is a very strong, easily palpable pulse.

Which is an expected finding of an abdominal examination of an adult?

High-pitched gurgles every 5 to 15 seconds

The nurse is asking the patient to stick out his tongue and move it back and forth. Which cranial nerve is the nurse testing?

Hypoglossal nerve (CN XII) The examiner should note smooth and coordinated movement.

The nurse is performing an abdominal assessment. What assessment techniques should be included in the assessment?

Inspection, Auscultation, Percussion, Palpation

When assessing a patient's abdomen, the nurse uses assessment techniques in which order?

Inspection, auscultation, and palpation

The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant?

Liver and gallbladder

A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding?

Narrowed airways Air moving within narrowed bronchi creates the wheezing sound.

The nurse is documenting in the chart. For documentation purposes, which term is used to describe a head that is of average size and shape?

Normocephalic The term normocephalic refers to a head of average size and shape.

While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease?

Pale, cool legs with diminished-to-absent dorsalis pulses

During inspection of the respiratory system the nurse documents which finding as abnormal?

Patient leaning forward with arms braced on the knees

The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the presence of abdominal ascites?

Percussion of dullness over dependent areas of the abdomen Option D is performed with the patient in several positions and is known as testing for shifting dullness.

The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the groin. Which examination technique is most appropriate for this patient?

Percussion of the costovertebral angle

The nurse is assessing a patient's dorsalis pedis pulse. What is the primary reason for this assessment?

Perfusion to the foot An absent pulse along with a foot that is cold and dusky indicates a lack of blood flow to the foot.

The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis?

Pneumonia Dullness can be caused by consolidation.

During a physical examination the nurse is unable to feel the patient's thyroid gland with palpation from an anterior approach. What is the appropriate action of the nurse at this time?

Recognize that this is an expected finding.

The nurse is preparing to perform an abdominal assessment. In which position should the patient be placed for abdominal assessment?

Supine The supine position optimizes the ability to inspect, auscultate, percuss, and palpate.

On auscultation of the heart, the nurse recognizes which expected finding?

The S1 heart sound is louder at the apex of the heart.

The nurse is percussing a patient's abdomen and hears tympany. Which anatomic features explain the finding of tympany with stomach percussion?

The stomach is hollow. Tympany may not be pronounced if the stomach is full.

The nurse notes a black umbilicus on a 5-day-old infant. What does this finding indicate?

This is a normal finding. The umbilical cord turns black before it falls off.

Which breath sounds are expected over the posterior chest of an adult?

Vesicular

Narrowing of the bronchi creates which adventitious sound?

Wheeze

How does the nurse palpate the chest for tenderness, bulges, and symmetry?

With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae

The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is considered abnormal?

Yellow or amber color to the tympanic membrane.

A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates:

a normal finding Bronchovesicular sounds are expected in this area of the chest.

A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects:

bacterial pneumonia. The sputum by bacterial pneumonia also will have a foul smell.

The nurse is aware that the greatest physical variation of ears among individuals of different races is:

consistency and color of cerumen. Asian and American Indian and Alaska natives have sparse, dry, flaky cerumen, whereas white and dark-skinned races have moist, sticky, and dark cerumen.

The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the __.

external intercostal muscles The intercostal muscles help push the chest wall outward.

The student nurse is learning how to use the ophthalmoscope. When performing an ophthalmoscopic examination, examine the patient's right:

eye with your right eye and the patient's left eye with your left eye. It allows the examiner to get close to the eye. It is hard to get as close to the patient's eyes when you have facial features such as the nose getting in the way. The examiner needs to be close to both eyes.

A patient reports shortness of breath with a gradual onset. The nurse suspects:

heart failure. Dyspnea of gradual onset that is accompanied by swelling and nocturia suggests congestive heart failure.