Nurs 301: PrepU ch 15, ch 21

Where is Erb's point located? 3rd right rib space 4th right rib space 3rd left rib space 4th left rib space

3rd left rib space

Where is Erb's point located? 4th right rib space 3rd right rib space 3rd left rib space 4th left rib space

3rd left rib space

A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record? 2+ 4+ 3+ 1+

4+

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? Stand at the client's left side and perform the entire assessment from this position Auscultate to determine the heart rate and if the rhythm is normal Elevate the head of bed until the examiner can comfortably reach the client Listen with the bell for the high pitched sounds of normal S1S2

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

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, tenderness

What is the most common type of hyperthyroidism?

Graves disease

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

The sternal angle at the right 2nd rib space is also known as what? The tricuspid area Erb's point The aortic area The mitral area

The aortic area

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first? "Is the pain worse on exertion?" "Is the pain worse when you are lying down?" "Do you have cramping pain?' "Do you have any pain or discomfort in your chest?"

"Do you have any pain or discomfort in your chest?"

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding? "Right carotid bruit auscultated" "Murmur heard over right carotid artery" "S2 sound heard over right carotid artery." "Split sound auscultated over right carotid artery"

"Right carotid bruit auscultated"

A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

Acute infection

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background?

Ask permission before palpating the head and neck

How should a nurse assess a client for pulse rate deficit? Assess for a difference between the apical and radial pulse Auscultate for split S1 at the base and apex Observe for a decrease in jugular venous pressure Check for pulse inequality between right and left carotid arteries

Assess for a difference between the apical and radial pulse

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

Bruit

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following? Cardiac workload Cardiac output Cardiac cycle Cardiac circulation

Cardiac cycle

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers?

Educating them about not drinking and driving

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

I must take thyroid hormone replacement medication for the rest of my life.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

In the midline, a few centimeters behind the tip of the mandible

A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this? Weaker ventricles due to low compliance Poorer conduction of electrical impulses in the heart due to fatty tissue Increased distance from the apex of the heart to the pre cordium Increased difficulty in locating the heart

Increased distance from the apex of the heart to the pre cordium

What nursing diagnosis would be most appropriate for a client admitted with heart failure? Impaired gas exchange Ineffective tissue perfusion Acute pain Risk for denial

Ineffective tissue perfusion

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report? Assess for thrills. Ensure that the client lies flat for the examination. Palpate the carotid pulse. Inspect for dependent edema.

Inspect for dependent edema.

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?

Meningitis

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

Migraine headache

When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point?

Mobile phones should only be used if there is a hands-free option available.

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

Notify the HCP immediately

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

Perform a focused assessment

When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest? Left sternal border , 3rd ICS Left mid-clavicular line, 5th ICS Right sternal border 4th ICS Right sternal border, 2nd ICS

Right sternal border, 2nd ICS

Where are the heart and great vessels located in the human body? The mediastinum, between the lungs above the diaphragm The peritoneum, below the diaphragm The peritoneum, above the diaphragm The mediastinum, between the lungs below the diaphragm

The mediastinum, between the lungs above the diaphragm

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?

characteristic symptoms

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of

cluster headaches

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

impending stroke

A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding? Heart rate is irregular Respiratory rate is too fast Heart enlargement is present Client has an increased chest diameter

Client has an increased chest diameter

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

How does the nurse differentiate a pleural friction rub from a pericardial friction rub? Turn the client on the right side; if the rub persists, it is pericardial Have the client hold his or her breath; if the rub persists, it is pericardial Auscultate the base of the heart; if a rub is present, it is pericardial Auscultate the upper back; if a rub is present, it is pleural

Have the client hold his or her breath; if the rub persists, it is pericardial

Across the lifespan, a nurse knows what characteristic of the female heart is consistently true? Is normally smaller than the male heart Is normally larger than a male heart Weighs more than a male heart Normally beats more slowly than a male heart

Is normally smaller than the male heart

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following? S1 Murmur S2 Ventricular gallop

Murmur

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?

hypothyroidism

The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.) inspecting the hands and lower legs inspecting and palpating the precordium auscultating the lungs examining the neck examining the face

inspecting the hands and lower legs inspecting and palpating the precordium examining the neck examining the face

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? left midclavicular line at the fifth intercostal space right of the midclavicular line at the third intercostal space right of midclavicular line at the fifth intercostal space left midclavicular line at the third intercostal space

left midclavicular line at the fifth intercostal space

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? Inability to breathe Painful breathing Rapid breathing Shortness of breath

Shortness of breath

While conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. This finding is most likely a manifestation of which problem? left-sided heart failure palpitations hypertension dextrocardia

left-sided heart failure

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? Inflammation of the pericardial sac Incompetent mitral valve Inability of the atria to contract Increased pressure within the ventricles

Inflammation of the pericardial sac

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound? Pericardial murmur Split sound Aortic ejection click Pericardial friction rub

Pericardial friction rub

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? Hematochezia Abdominal pain Tenesmus Orthopnea

Orthopnea

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

Sternocleidomastoid

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply. Use a low sodium seasoning to flavor food. Walk briskly 30 minutes per day. Increase consumption of dairy products. Choose foods like bananas and sweet potatoes. Consume two to three glasses of red wine daily.

Use a low sodium seasoning to flavor food. Walk briskly 30 minutes per day. Choose foods like bananas and sweet potatoes.

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

hyperthyroidism