Advanced Health Assessment Test 1

The pneumatic attachment to the otoscope is used to evaluate which characteristic of the tympanic membrane? A. Vibrations B. Mobility C. Tension D. Strength

B. Mobility The pneumatic attachment of the otoscope is used to provide information about tympanic membrane mobility and the middle ear space, such as the presence of middle ear effusion. The otoscope should have no air leaks.

Mr. Jeffries is a 37-year-old carpenter who presents to your office with a complaint of visual disturbances. On examination, you notice inequality in pupil size which you identify as: A. mydriasis. B. esotropia. C. anisocoria. D. meiosis.

C. anisocoria. Anisocoria, inequality of pupillary size, is a common variation but may also occur in a large range of disease states.

To accurately assess height velocity, a child's height can be measured: A. at 6-month intervals. B. at 9-month intervals. C. at 12-month intervals. D. at 15-month intervals.

C. at 12-month intervals. To calculate height velocity, determine the change in height over a time interval (e.g., 1 year). Shorter time intervals may reflect seasonal variations in growth. Make height measurements as close to 12 months apart as possible, no fewer than 10 months and no more than 14 months. (See the website for gender-specific height velocity growth curves during adolescence.)

Mr. Javed is an Arab gentleman who is experiencing a sore throat. He is most likely to treat this with: A. meditations and prayer. B. ginger root, a "hot" medicine. C. barley water, a "cold" food. D. no treatment at all.

C. barley water, a "cold" food. Barley water is an example of cold treatment. It is applicable because the condition would be considered a hot condition.

Breath sounds normally heard over the trachea are called: A. bronchovesicular. B. amphoric. C. bronchial. D. vesicular.

C. bronchial. Bronchial or trachial (tubular) breath sounds are heard only over trachea. They are high pitched, loud, have long expirations, and are sometimes a bit longer than inspiration.

Which would be an expected finding when palpating the adult chest? A. A costal angle of 100 degrees B. Crackling over the sternal notch C. Greater right chest expansion D. Inflexibility of the xiphoid

D. Inflexibility of the xiphoid Expect bilateral symmetry and some elasticity of the rib cage, but the sternum and xiphoid should be relatively inflexible and the thoracic spine rigid.

The AP-to-lateral diameter ratio of the chest in infants is approximately: A. 1:2. B. 1:3. C. 2:1. D. 1:1.

D. 1:1. The chest of the newborn is generally round, the AP diameter approximating the lateral diameter, and the circumference is roughly equal to that of the head until the child is about 2 years old.

What is the expected weight gain of a neonate from 2 weeks to 3 months of age? A. 15 g/day B. 20 g/day C. 25 g/day D. 30 g/day

D. 30 g/day After losing up to 10% of their birth weight, newborns regain that weight within 2 weeks and then gain weight at a rate of approximately 30 g (1 oz) per day. This decreases starting at about 3 months of age.

Mrs. Howell brings her 13-year-old daughter for a routine well visit. Which of the following is relevant information for a history and examination of a child's eyes and vision? A. Immunization history B. Growth milestones C. Birth weight D. Academic performance

D. Academic performance History of school-age children related to eyes and vision should include information regarding the necessity of sitting near the front of the classroom to see the teacher's work and poor school performance not explained by intellectual ability.

Which information should be included in the history of a patient with asthma? A. Family members with asthma B. Onset and duration of the current problem C. Allergy skin test results D. All of the above

D. All of the above Asthma is a small airway obstruction caused by inflammation and hyperreactive airways. Answers a-c should be asked of patients with asthma as the responses to questions about these topics provide clues for focusing the physical examination and the development of an appropriate diagnostic evaluation.

In which group is a jugular venous hum an ordinarily expected examination finding? A. Older adults B. Pregnant women C. Native Americans/American Indians D. Children

D. Children A venous hum, common in children, usually has no pathologic significance. It is caused by the turbulence of blood flow in the internal jugular veins.

Where would you palpate a carotid pulse? A. Superior to the clavicle at the midclavicular line B. Superior and lateral to the cricoid cartilage C. Fingerbreadth above the suprasternal notch D. Inferior and medial to the angle of the jaw

D. Inferior and medial to the angle of the jaw The carotid pulse is located just medial to and below the angle of the jaw.

For which assessment would you use an otoscope with a pneumatic attachment? A. Patency of the nares B. Mobility of the tympanic membrane C. Pressure in the Eustachian tube D. Presence of impacted cerumen

B. Mobility of the tympanic membrane The pneumatic attachment of the otoscope is used to provide information about tympanic membrane mobility and the middle ear space, such as the presence of middle ear effusion. The otoscope should have no air leaks.

The tubing of a stethoscope should be 12 to 18 inches to prevent: A. transmission of external noise. B. tangling of the tubing in the examiner's clothing or pockets. C. distortion of sounds during auscultation. D. magnification of the transmitted sounds.

C. distortion of sounds during auscultation. The tubing is thick, stiff, and heavy; this conducts better than thin, elastic, or very flexible tubing. The length of the tubing is between 30.5 and 40 cm (12 and 18 inches) to minimize distortion.

A bony protuberance at the midline of the hard palate that is of no clinical significance is called: A. aphthous torinus. B. torus palatinus. C. palates crypts. D. molluscum palatinus.

B. torus palatinus. The hard palate may have a bony protuberance at the midline, called torus palatinus, an expected variant.

Screening for auditory function in an individual begins: A. after the otoscopic examination. B. when the patient responds to your questions and directions. C. before you begin the physical examination. D. after you have cleaned out the ears.

B. when the patient responds to your questions and directions. Hearing screening begins when the patient responds to your questions and directions. Note any behaviors such as cupping a hand behind the ear or tilting an ear toward you when listening.

To inspect the chest, you should observe: A. after the patient begins to cough. B. while the patient breathes normally. C. while the patient holds his or her breath. D. with your palm on the patient's chest.

B. while the patient breathes normally. Inspect the chest wall movement during respiration. Again, different angles of illumination will aid inspection and help delineate chest wall movement and possible deformities.

Tenderness arising from the gallbladder, kidney, or liver may be assessed by: A. ballottement. B. light palpation. C. fist percussion. D. scratch test.

C. fist percussion. Fist percussion is most commonly used to elicit tenderness arising from the liver, gallbladder, or kidneys.

Which examination technique would you use when checking for Chvostek sign? A. Inspection B. Auscultation C. Palpation D. Percussion

D. Percussion Percussion of the head and neck is not routinely performed. One exception is when evaluating for hypercalcemia; percussion on the masseter muscle may produce a hyperactive masseteric reflex, Chvostek sign.

What is the fibrous sac that encases and protects the heart called? A. Mediastinum B. Precordium C. Endocardium D. Pericardium

D. Pericardium The pericardium is a tough, double-walled, fibrous sac encasing and protecting the heart.

Which type of apnea is least worrisome? A. Primary apnea B. Secondary apnea C. Apneustic breathing D. Periodic apnea of the newborn

D. Periodic apnea of the newborn Periodic apnea of the newborn is a normal condition characterized by an irregular pattern of rapid breathing interspersed with brief periods of apnea.

Which of the following is the function of the lens? A. Converts light impulses into electrical impulses for image formation B. Controls the amount of light entering the eye C. Coordinates eye movement D. Permits images from varied distances to be focused on the retina

D. Permits images from varied distances to be focused on the retina The lens is a biconvex, transparent structure located immediately behind the iris. It is supported circumferentially by fibers arising from the ciliary body. The lens is highly elastic, and contraction or relaxation of the ciliary body changes its thickness, thereby permitting images from varied distances to be focused on the retina.

Mrs. Tubbs is a 42-year-old patient who presents to your office for a routine follow-up. Which is the best technique for hearing low-pitched filling sounds of the heart? A. Place the patient in supine position and listen with the bell of the stethoscope. B. Place the patient in a sitting position and listen with the diaphragm of the stethoscope. C. Place the patient in a sitting position and listen with the bell of the stethoscope. D. Place the patient in a left lateral recumbent position and listen with the bell of the stethoscope.

D. Place the patient in a left lateral recumbent position and listen with the bell of the stethoscope. A thorough examination of the heart requires the patient to assume a variety of positions: sitting erect and leaning forward, lying supine, and being in the left lateral recumbent position. To best hear the low-pitched filling sounds in diastole, place the patient in left, lateral recumbant position and listen with the stethoscope

Mrs. Janker is a 58-year-old patient who presents to your office with recurrent respiratory problems. You best assess the quality of tactile fremitus by palpating at which location? A. Along the costal margin and xiphoid process B. In the suprasternal notch along the clavicle C. Parasternally at the second intercostal space D. Posterolaterally beneath the scapula

D. Posterolaterally beneath the scapula Note the quality of the tactile fremitus, the palpable vibration of the chest wall that results from speech or other verbalizations. Fremitus is best felt posteriorly and laterally at the level of the bifurcation of the bronchi. Two methods for evaluating tactile fremitus are with the palmar surface of both hands and with the ulnar aspect.

The plan is divided into which three sections? A. Diagnostics, therapeutics, and medicritics B. Therapeutics, diacritics, and education C. Diagnostics, diacritics, and education D. Therapeutics, diagnostics, and education

D. Therapeutics, diagnostics, and education The plan is divided into three sections: diagnostics, therapeutics (if known), and patient education.

While examining the skin of an 87-year-old woman, the nurse observes significant tenting. Which of the following best explains that finding? A. Small tags of skin form on the neck. B. The skin becomes thin and takes on a parchment-like appearance. C. The skin becomes dry with significant flaking. D. There is a loss of adipose tissue and elasticity.

D. There is a loss of adipose tissue and elasticity. Tenting occurs in the older adult as a result of loss of adipose tissue and elasticity. The skin often appears to hang loosely on the bony frame as a result of a general loss of elasticity, loss of underlying adipose tissue, and years of gravitational pull.

Mrs. Becker is a 68-year-old patient who presents to your office. On examination, you palpate a fibrotic, irregular thyroid. What is your primary conclusion about this finding? A. The thyroid needs further examination. B. A malignancy is likely. C. An autoimmune disease is likely. D. This is a normal finding in an older adult.

D. This is a normal finding in an older adult. The rate of T4 production and degradation gradually decreases with aging, and the thyroid gland becomes more fibrotic.

A 6-month-old infant is brought to the clinic for immunizations. While examining the baby, the examiner notes that the anterior fontanel has not closed. What is the significance of this finding? A. This indicates a slight developmental delay. B. This suggests a nutritional deficiency. C. This is consistent with hydrocephaly. D. This is a normal finding.

D. This is a normal finding. The posterior fontanel usually closes by 2 months of age and the anterior fontanel by 12 to 15 months of age.

Resonance refers to the percussion tone that is heard over the: A. liver. B. muscle. C. stomach. D. lung.

D. lung. Sound waves that are heard as percussion tones that arise from vibrations 4 to 6 cm deep in the body tissue are called resonance.

The examiner notes enlarged tonsils in a young child. The examiner should recognize that this: A. is an indication of a retropharyngeal abscess. B. may be an early indication of Epstein-Barr virus. C. is an indication that the child has lymphoma. D. may be a normal finding.

D. may be a normal finding. The palatine tonsils are commonly referred to as "the tonsils." Small and diamond shaped, they are set between the palatine arches on either side of the pharynx just beyond the base of the tongue. The palatine tonsils may be enlarged in children; this in itself is not a problem.

When examining a patient's ear, you hear a cracking sound when you ask the patient to yawn. This finding is indicative of: A. external otitis media. B. otitis externa. C. acute otitis media. D. otitis media with effusion.

D. otitis media with effusion. A sticking or cracking sound on yawning or swallowing is indicative of otitis media with effusion.

The right and left scapular lines are located: A. superior to each scapula. B. inferior to each scapula. C. lateral to the midaxillary lines. D. parallel to the vertebral line.

D. parallel to the vertebral line. In conjunction with the anatomic landmarks of the chest, the following imaginary lines on the surface will help localize the findings on physical examination to include the right and left scapular lines, which are parallel to the vertebral line, through the inferior angle of the scapula when the patient is erect.

Fetal gas exchange is mediated by the: A. lungs. B. heart. C. amniotic fluid. D. placenta.

D. placenta. Fetal gas exchange is mediated by the placenta. Relatively passive respiratory movements occur throughout gestation; they do not open the alveoli or move the lung fields.

Adults have two types of hair, which are identified as: A. primary and secondary. B. terminal and original. C. vellus and telogus. D. terminal and vellus.

D. terminal and vellus. Adults have both vellus and terminal hair. Vellus hair is short, fine, soft, and nonpigmented. Terminal hair is coarser, longer, thicker, and usually pigmented.

When you find an enlarged lymph node on examination, the most appropriate question for the examiner to ask a patient is: A. "Are you aware of any lumps?" B. "Have you had a change in appetite?" C. "Do your lymph nodes hurt?" D. "Where are your largest lymph nodes?"

A. "Are you aware of any lumps?" When a lymph node is enlarged, information related to its onset and duration is important to obtain if possible. Asking if the patient is aware of any lumps determines whether information about onset and duration may be obtained.

Mr. Jerry Spenser, a 26-year-old homosexual man, is having a health history taken. Which question regarding sexual activity would most likely hamper trust between Jerry and the interviewer? A. "Are you married or do you have a girlfriend?" B. "Tell me about your living situation." C. "Are you sexually active?" D. "Are your partners men, women, or both?"

A. "Are you married or do you have a girlfriend?" The sexual orientation of a patient must be known if appropriate continuity of care is to be offered. The apprehension these patients may feel in revealing their preferences should be respected. Reassuring, nonjudgmental words help. Trust is best achieved if questions are gender neutral and open ended. If you use a nonjudgmental approach, a variety of questions applicable to any patient and any sexual circumstance becomes possible.

Which of the following questions helps the health care provider assess the location of the pain? A. "Does the pain travel or radiate?" B. "Where did the pain start?" C. "When did the pain start?" D. "What increases the pain?"

A. "Does the pain travel or radiate?" To answer this question, the patient must identify the pain's point of origin, thus identifying a location. Answer a is the best choice. Answers b, c, and d help the health care provider assess duration, onset, and conditions that aggravate or exaggerate the pain.

Mrs. Jones is a 45-year-old patient who presents to your office with a complaint of fatigue. On examination, you observe a blackish area on the top surface of the tongue. Mrs. Jones tells you that her tongue is painful. Which question by the examiner would be helpful in explaining this finding? A. "Have you been taking antibiotics lately?" B. "Have you injured your tongue?" C. "Have you been diagnosed with mouth cancer before?" D. "When was the last time you brushed your teeth?"

A. "Have you been taking antibiotics lately?" The hairy tongue with yellow-brown to black elongated papillae on the dorsum sometimes follows antibiotic therapy.

Mr. Sandstrom has come for his routine appointment for his hypertension. He is not experiencing medication side effects or other health problems. Which of the following questions is most appropriate to ask when you begin the interview? A. "How have you been doing since your last visit?" B. "Have you been taking your medications?" C. "What brings you to the office today?" D. "How are you doing with your hypertension?"

A. "How have you been doing since your last visit?" At the start, greet the patient and those with the patient. Begin by asking open-ended questions ("How have you been feeling since we last met?" "What questions would you like to discuss?" "What do you want to make sure we cover in today's visit?").

Mr. Black is a 57-year-old patient who presents for a complaint of chest pain. Which of the following is the best way to document an individual's chief complaint? A. "I'm having some pain in my chest." B. Patient states having some substernal chest pain. C. Patient experiencing angina. D. CC: Impending MI.

A. "I'm having some pain in my chest." The chief concern or presenting problem is a brief description of the patient's main reason for seeking care. The information may be stated verbatim in quotation marks.

Which behavior described by a parent indicates that an infant or young child may have a hearing problem? A. "My 2-month-old baby does not seem to respond to loud noises." B. "My 5-month-old baby is babbling, but she is not yet saying any words." C. "Sometimes my 3-year-old does not pay attention to me." D. "When my 15-month-old baby is talking, I sometimes have a hard time understanding her."

A. "My 2-month-old baby does not seem to respond to loud noises." From birth to 3 months of age it is normal for infants to startle, wake, or cry when hearing a loud sound. At 4 months, the infant should turn its head toward an interesting sound, localizing sound on a horizontal plane.

Which example illustrates a vague or nondescriptive term? A. "Skin color is normal." B. "Skin turgor is elastic." C. "Skin is thin and smooth." D. "Skin is warm and dry."

A. "Skin color is normal." Wording of findings should be precise and objective so that their meaning is clear to all health providers involved in the patient's care. Use of words such as normal, good, poor, and negative should be avoided, because these words are open to various interpretations by other examiners.

Mrs. Green presents to your office with a long-standing history of fibromyalgia. Which of the following questions will assess the quality of her pain? A. "What does your pain feel like?" B. "Is the pain medication helping?" C. "How many days of the month do you experience the pain?" D. "What makes the pain worse?"

A. "What does your pain feel like?" Asking "What does your pain feel like?" allows Mrs. Green the opportunity to subjectively describe her pain. Although the other choices are appropriate components of the comprehensive pain assessment, they do not deal with the quality of pain.

Which is a health care disparity identified in the 2013 Centers for Disease Control and Prevention (CDC) Health Disparities and Inequalities Report? A. A higher percentage of black women died from coronary heart disease before age 75 than white women. B. Non-Hispanic white women experienced a higher infant mortality rate than non-Hispanic black women. C. A higher percentage of white men older than age 50 died from coronary artery disease than black men. D. Asian/Pacific Islanders were uninsured at a higher rate than Hispanics.

A. A higher percentage of black women died from coronary heart disease before age 75 than white women. Data from the 2013 CDC Health Disparities and Inequalities Report revealed a variety of health care disparities such as that, compared with white women, a much higher percentage of black women died from coronary heart disease before age 75 (37.9% vs. 19.4%).

Which of the following is a warning sign of squamous cell carcinoma? A. A persistent scaly red patch B. Shiny nodules that are pearly C. Scarlike area that is white, yellow, or waxy D. An open sore that takes 6 weeks to heal

A. A persistent scaly red patch Squamous cell cancer is the second most common skin cancer. Objective signs include a persistent scaly red patch with irregular borders with or without crusting or bleeding, elevated growth with a central depression, wartlike growth that may or may not have crusting or bleeding, and an open sore that may have crusting.

Which behavior is least likely to facilitate an interview with a patient who is dissembling? A. Allow the topic to be changed. B. State "I noticed that you changed the topic." C. Use gentle questioning to help the patient explore the topic. D. Return to the topic at later time in the interview.

A. Allow the topic to be changed. Patients may not always tell the whole story or even the truth, either purposely or unconsciously. Do not push too hard when you think this is happening. Allow the interview to go on and then come back to a topic with gentle questioning. Unless there is concern about the safety of the patient or another individual, learning all that is necessary may not come in one sitting. You may have to pursue the topic at a later visit or perhaps with other members of the family, the patient's friends, or your professional associates.

When taking a patient's history, you are asked questions about your personal life. What is the best response to facilitate the interview process? A. Answer briefly and then refocus on the patient's history. B. Give as much detail as possible about the asked information. C. Ignore the question and continue with the patient's history. D. Tell the patient that it is inappropriate to answer personal questions.

A. Answer briefly and then refocus on the patient's history. Patients will sometimes ask about you. Although you are not the point, you may be comfortable revealing some relevant aspects of your experience ("I have trouble remembering to take medicines, too"). A direct answer will usually do. Often, simply informing your patients that you have experienced similar life events (e.g., illness, pregnancy, and childbirth) can help alleviate fears and help in the identification of the patient's concerns. The message that you are a "real" person can lead to a trust-enhancing or even therapeutic exchange.

Mr. Herrara is a 42-year-old patient who presents for routine well visit. On examination during cardiac auscultation, you note a midsystolic murmur with a medium pitch; a coarse thrill is palpated as well. These findings are consistent with which condition? A. Aortic stenosis B. Aortic regurgitation C. Pulmonic stenosis D. Mitral stenosis

A. Aortic stenosis Aortic stenosis is heard over the aortic area as an ejection sound at the second right intercostal boader. Characteristic subjective and objective data include midsystolic murmer with a medium pitch, with a coarse palpable thrill.

Mrs. Tucker is a 34-year-old patient who presents to your office with a complaint of a sore throat. On examination, you find an enlarged thyrolinguofacial lymph node. Which of the following would you assess? A. Area proximal to the enlarged node B. Posterior superficial cervical chain C. Occipital nodes D. Preauricular nodes

A. Area proximal to the enlarged node If you discover an enlarged node, consider the associated region drained by the node to suggest possible sources for a presenting problem, as well as explore the accessible adjacent areas and regions drained by those nodes for signs of possible infection or malignancy.

A young Native American/American Indian child with severe abdominal pain and fever is brought to the clinic by his mother and grandmother. On examination, you find a foul-smelling cloth wrapped around the child's abdomen. If not removed, the cloth will interfere with the completion of the examination. Of the following, which action best demonstrates cultural sensitivity? A. Ask about its purpose and then remove the cloth. B. Ignore the cloth. C. Ask permission to remove the cloth. D. Inform the family that the cloth will be replaced immediately after the abdominal examination.

A. Ask about its purpose and then remove the cloth. Asking about the purpose of the cloth before removing the cloth best depicts cultural sensitivity. Beliefs and behaviors that have an effect on patient assessment will exist. When differences exist, be certain that you grasp exactly what the patient means and know exactly what the patient thinks you mean in words and actions. Asking the patient if you are not sure is far better than making a damaging mistake. Avoid assumptions about cultural beliefs and behaviors made without validation from the patient.

During auscultation of a patient's heart, the sounds from the TV are interfering with adequate hearing of the heart sounds. Which of the following options would be best in this situation? A. Ask the patient to turn off/mute the TV for a couple of minutes. B. Turn up the sound on the stethoscope. C. Come back when the TV is off. D. Skip the auscultation examination for this time.

A. Ask the patient to turn off/mute the TV for a couple of minutes. One of the most difficult achievements in auscultation is learning to isolate sounds. You cannot hear everything all at once. The environment should be quiet and free from distracting noises.

Mrs. Delman brings her 1-month-old infant in for a routine examination. Which of the following is considered a routine part of a newborn examination? A. Assessing red reflex B. Assessing extraocular movements with six fields of gaze C. A fundoscopic examination D. Assessing visual acuity

A. Assessing red reflex The red reflex is checked bilaterally in the newborn. Interruption of the red reflex may indicate congenital cataracts or retinoblastoma or other serious intraocular pathologic condition. A funduscopic examination is difficult to conduct on a newborn or young infant and is generally deferred until the infant is 2 to 6 months of age unless there is concern about a congenital eye abnormality, suspicion of physical abuse (shaken baby syndrome), trauma, or need for an assessment for retinopathy of prematurity.

Which condition is characterized by paroxysmal coughing and inspiratory and expiratory wheezing? A. Asthma B. Emphysema C. Pneumonia D. Pneumothorax

A. Asthma Subjective symptoms of asthma include episodes of paroxysmal dyspnea, as well as objective symptoms of tachypnea, paroxysmal coughing with wheezing on expiration and inspiration.

Where are the semilunar valves located? A. At the exit of each ventricle where the great vessels originate B. Between the left ventricle and left atria C. At the bifurcation of the pulmonary ascending aorta D. At the entrance of the superior vena cava into the right atria

A. At the exit of each ventricle where the great vessels originate The four chambers of the heart are connected by two sets of valves: the atrioventricular and semilunar valves. The two semilunar valves each have three cusps. The pulmonic valve separates the right ventricle from the pulmonary artery. The aortic valve lies between the left ventricle and the aorta. Contraction of the ventricles (systole) opens the semilunar valves, causing blood to rush into the pulmonary artery and aorta. When the ventricles relax (diastole), the valves close, shutting off any backward flow into the ventricles.

Mr. Venturi is a 55-year-old marathon runner who presents to your office with a complaint of many days of fever, shortness of breath, and some chest discomfort. On examination, you note clinical signs of congestive heart failure. Which disease process should you consider? A. Bacterial endocarditis B. Infarction C. Myocarditis D. Cardiac tamponade

A. Bacterial endocarditis Bacterial endocarditis is an infection of the endothelial layer of the heart and valves. It presents suddenly like congestive heart failure, with fever and chest discomfort.

Physical differences between black and white Americans include which of the following? A. Blacks have a greater incidence of pigmentary demarcation lines. B. Whites have greater stratum lucidum. C. Blacks synthesize reticulum fibers more readily. D. Whites eliminate sweat, urea, and lactic acid more quickly.

A. Blacks have a greater incidence of pigmentary demarcation lines. Individuals with dark skin may show pigmentary demarcation lines. These lines, a normal variation, mark the border between deeply pigmented skin and lighter pigmented skin. They are most commonly seen on the arms, legs, chest, and back and have been reported most often in black and Japanese populations.

How is a blood pressure reading affected if a wide adult cuff is used on a small child? A. Blood pressure readings will be lower. B. Blood pressure readings will be higher. C. Systolic readings will be falsely high and diastolic falsely low. D. Blood pressure readings will be variable because correct cuff size is a matter of comfort.

A. Blood pressure readings will be lower. The correct cuff size ensures that equal pressure will be exerted around the artery, resulting in an accurate measurement. If the cuff is too wide, the blood pressure will be underestimated.

On examination, the auditory canal of a 13 year old is found to be obstructed with cerumen. Which tool would you use to clean out an obstructed auditory canal? A. Body temperature water irrigation B. Cerumen spoon C. Specialized otoscope speculum D. Lubricated cotton-tipped swab

A. Body temperature water irrigation If the patient has a tympanic membrane obscured by cerumen, the canal can be cleaned by warm water irrigation or by a cerumen spoon. Irrigation with water at body temperature is preferable in young patients. The auditory canal is easily abraded, and using a cerumen spoon has the potential to cause pain and bleeding.

Which of the following are functions of the skin (select all that apply)? A. Secrete sweat, urea, and lactic acid B. Produce vitamin C from precursors in the skin C. Contribute to blood pressure regulation by dilation of skin blood vessels D. Protect against microbial/foreign substance invasion and minor physical trauma

A. C. D. The skin is the first layer of protection against microbial/foreign substance invasion and minor physical trauma. It excretes sweat, urea, and lactic acid, and it contributes to blood pressure regulation through constriction of skin blood vessels.

Mrs. Jones is a 34-year-old pregnant patient. For what benign effect of pregnancy are you assessing when you inspect her face hyperpigmentation? A. Chloasma B. Vitiligo C. Cloaca D. Hyperpigmentosa

A. Chloasma Beginning after 16 weeks of gestation, many pregnant women develop blotchy, brownish hyperpigmentation of the face, particularly over the malar prominences and the forehead. This chloasma, also called "mask of pregnancy," may further darken with sun exposure, but generally it fades after delivery.

Mr. Black is a 66-year-old patient with a history of herpes simplex. He presents to your office with a concern of visual disturbances. Which of the following would explain why this individual may be unaware of an infection or injury to an eye? A. Decreased corneal sensitivity B. Diminished tearing C. Reduced visual acuity D. Increased density of the lens

A. Decreased corneal sensitivity Decreased corneal sensation is often associated with diabetes and herpes simplex and herpes zoster viral infections and after trigeminal neuralgia surgery.

Which examination finding is consistent with emphysema? A. Decreased fremitus B. Dullness with chest percussion C. Trachea in midline position D. An ammonia-like odor on the patient's breath

A. Decreased fremitus Decreased fremitus is a condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function. Decreased or absent fremitus may be caused by excess air in the lungs or may indicate emphysema, pleural thickening or effusion, massive pulmonary edema, or bronchial obstruction.

Which factor best accounts for the changes in the head circumference in adolescence? A. Development of air sinuses and thickening of the scalp and skull B. Decrease of fluid in the brain C. Brain growth continuing until 18 years of age D. Development of ventricles increasing brain size

A. Development of air sinuses and thickening of the scalp and skull During adolescence, the size of the head further increases because of the development of air sinuses and thickening of the scalp and skull. Answers b, c, and d are incorrect.

Which is a serious risk factor for respiratory disability in older adults? A. Difficulty swallowing B. An environmental temperature below 75°F C. Frequent stair climbing D. A history of skin rashes

A. Difficulty swallowing Difficulty swallowing for any reason poses a risk factor for any population. Older patients may have more difficulty breathing deeply and holding their breath than younger patients, and they may tire more quickly even when well.

Nociceptors transmit pain impulses to which area of the spinal cord? A. Dorsal horn B. Anterior horn C. Spinothalamic tract D. Spinoreticular tract

A. Dorsal horn Pain impulses travel from the nociceptors (free nerve endings) at the site of injury to the dorsal horn of the spinal cord through the ascending spinal tracts to the thalamus and cerebral cortex.

With which condition should the examiner expect the costal angle to be greater than 90 degrees? A. Enlarged heart B. Pneumothorax C. Infant respiratory distress syndrome D. Atelectasis

A. Enlarged heart A prolonged expiration and bulging on expiration are probably caused by airway outflow obstruction or the valvelike action of compression by a tumor, aneurysm, or enlarged heart. When this happens, the costal angle widens beyond 90 degrees.

Mr. Bowers is a 55-year-old patient who presents to your office. On examination, you note a mass filling the area of the suprasternal notch at the anterior base of the neck; the mass glides upward when the patient swallows. Which condition is consistent with this finding? A. Enlarged thyroid B. Enlarged trachea C. Localized infection D. Tracheal tugging

A. Enlarged thyroid Marked edema of the neck may be associated with local infections (e.g., cervical lymphadenitis). A mass filling the base of the neck or visible thyroid tissue that glides upward when the patient swallows may indicate an enlarged thyroid.

In the naturalistic or holistic approach, which of the following statements accurately reflect the naturalist belief? A. External factors must be kept in perfect balance. B. A person eats and uses only naturally grown foods. C. Restoring a disturbed balance requires well-heated foods. D. All prescribed medications are considered "cold."

A. External factors must be kept in perfect balance. A more naturalistic or "holistic" approach broadens the context. It views our lives as part of a much greater whole (the entire cosmos) that must be in harmony. If the balance is disturbed, illness can result. The goal, then, is to retrieve balance and harmony.

Mrs. Cousins is a 35-year-old patient who presents to your clinic. Your diagnosis is acute cervical lymphadenitis. Which of the following is the most likely etiology? A. Group A β-hemolytic strep B. Pneumocystis carinii infection C. Milroy disease D. Infectious mononucleosis

A. Group A β-hemolytic strep Acute lymphadenitis is infection and inflammation of a lymph node. Group A β-hemolytic streptococci and coagulase-positive staphylococci are the most common causes of the infection.

Body system examination data are described and recorded as: A. objective data. B. impartial data. C. systematic data. D. synthetic data.

A. objective data. Objective data are the findings resulting from direct observation—what you see, hear, and touch. Record the objective data by body systems and anatomic location.

Mrs. Hernandez is a 45-year-old woman who presents to your office for a follow-up examination regarding her persistent low back pain. She describes her pain as an 8 on a scale of 1 to 10. On examination, her vital signs are normal and her examination is unremarkable. Which statement best explains these findings? A. Fewer changes in vital signs are found with chronic pain. B. She is exhibiting drug-seeking behavior. C. She has a low tolerance for pain. D. The only real pain in the back is referred pain.

A. Fewer changes in vital signs are found with chronic pain. Chronic pain is slowly transmitted by small fibers and with time patients may adapt. Answers b, c, and d are inappropriate responses in this scenario.

What part of the hand is best for the examiner to use to palpate a superficial mass detected in the skin? A. Finger pads B. Heel of the hand C. Dorsal surface of the hand D. Ulnar surface of the hand

A. Finger pads Certain parts of your hands and fingers are better than others for specific types of palpation. To determine position, texture, size, consistency, fluid, crepitis, form of a mass, or structure use the palmer surface of the fingers and finger pads.

Which occurrence marks the completion of skeletal growth? A. Fused epiphyses of long bones B. Eighteenth birthday C. Fused epiphyses of all bones D. Fifteenth birthday

A. Fused epiphyses of long bones Skeletal growth is considered complete when the epiphyses of long bones have completely fused during late puberty. Although more than 90% of the skeletal mass is present by 18 years of age, this is incorrect because it does not apply to everyone. Answers c and d are false statements.

Where on the body would you palpate the epitrochlear lymph nodes? A. Groove between the triceps and the biceps at the elbow B. Deep in the medial aspect of the groin C. Just in front of the tragus D. At the angle of the mandible

A. Groove between the triceps and the biceps at the elbow To palpate the epitrochlear nodes, support the arm in one hand as you explore the elbow with the other. Grasp the patient's right wrist, palm facing up, with your left hand. The elbow should be in a relaxed position at approximately 90 degrees. Place your right hand under the patient's right elbow and cup your fingers around the elbow to find the area that is proximal and slightly anterior to the medical epicondyle of the humerus. There is a groove between the triceps and biceps muscles. Here is where you find the epitrochlear lymph nodes.

On palpation of an older individual's skin, you observe "tenting." Which of the following would be most appropriate for you to do in regard to this condition? A. Have the individual further evaluated for dehydration. B. Refer the client for punch biopsy of the skin. C. Inform the individual to be especially vigilant in self-screening for skin cancer. D. Observe the skin carefully for other manifestations of loss of skin integrity.

A. Have the individual further evaluated for dehydration. In the older individual, the skin often appears to hang loosely on the bony frame as a result of a general loss of elasticity, loss of underlying adipose tissue, and years of gravitational pull. You may observe tenting of the skin when testing for turgor. Tenting can be indicative of dehydration. How quickly the tent disappears provides a clue to the degree of dehydration

You are examining a patient who presented with a complaint of shortness of breath. What direction do you give the patient to enable you to distinguish between a respiratory friction rub and a cardiac friction rub? A. Hold your breath. B. Lean forward. C. Say "ninety-nine" while you palpate the anterior chest. D. Turn on your right side.

A. Hold your breath. A friction rub occurs outside the respiratory tree. It has a dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration. It may have a machine-like quality. Over the pericardium, this sound suggests pericarditis; over the lungs, pleurisy. The respiratory rub disappears when the breath is held; the cardiac rub does not.

Antibodies produced by B cells create which of the following type of immunity? A. Humoral immunity B. Cellular immunity C. Immunocompetent immunity D. Effector immunity

A. Humoral immunity Lymphocytes that are derived primarily from bone marrow (i.e., B lymphocytes) produce antibodies and are characterized by the various arrangements of immunoglobulins on their surface. They are involved in the humoral immune response.

Where are the superficial lymph nodes located? A. In the subcutaneous connective tissue B. In the fascia C. In the muscle D. Within body cavities

A. In the subcutaneous connective tissue Superficial nodes are located in subcutaneous connective tissues, and deeper nodes lie beneath the fascia of muscles and within the various body cavities. The nodes are numerous and tiny, but some of them may have diameters as large as 0.5 to 1 cm.

The examiner notes an obvious odor to the patient when they first meet. Which examination technique is being applied? A. Inspection B. Palpation C. Percussion D. Auscultation

A. Inspection Inspection is the process of observation. Inspection—unlike palpation, percussion, and auscultation—can continue throughout the history-taking process and during the physical examination.

Which examination technique is applied throughout the entire examination and interview process? A. Inspection B. Palpation C. Percussion D. Auscultation

A. Inspection Inspection—unlike palpation, percussion, and auscultation—can continue throughout the history-taking process and during the physical examination.

The head circumference of a neonate at term is found to be 34 cm. What meaning would you assign to this finding? A. It is normal. B. It is small for gestational age. C. It is suggestive of hydrocephaly. D. It is consistent with microcephaly.

A. It is normal. Expected head circumferences for term newborns range between 32.5 and 37.5 cm (12.5 to 14.5 inches) with a mean of 33 to 35 cm (13 to 14 inches).

Which is a normal physical variation commonly seen in preterm infants? A. Long, narrow head B. Broad nose bridge C. Low-set ears D. Webbed neck

A. Long, narrow head Head shape with an unusual contour may be related to premature or irregular closing of suture lines. Preterm infants often have long, narrow heads (brachiocephaly) because their soft cranial bones become flattened with positioning and the weight of the head.

Mrs. Jones presents with a complaint of a spot on her skin. Which type of lesion can develop in an already present nevi? A. Malignant melanoma B. Squamous cell carcinoma C. Basal cell carcinoma D. Kaposi sarcoma

A. Malignant melanoma Malignant melonoma is the most lethal form of skin cancer that develops from melanocytes. Squamous cell carcinoma, basal cell carcinoma, and Kaposi sarcoma rarely develop in an already existing nevi.

Which finding could indicate an intrathoracic infection? A. Malodorous breath B. Protrusion of the clavicle C. Clubbing of the nail beds D. Kussmaul respirations

A. Malodorous breath Smell the breath; pulmonary infection may make it malodorous.

Mr. Jones is a 72-year-old patient who presents with a complaint of fever and fatigue. On examination, you note tachycardia and pulsus alternans. Of which condition are these signs and symptoms most suggestive? A. Myocarditis B. Left ventricular hypertrophy C. Cardiac tamponade D. Cor pulmonale

A. Myocarditis Myocarditis is focal or diffuse inflammation of the myocardium. Patients with this disorder may report symptoms of fatigue, fever, palpitations, and dyspnea. The examiner may assess pulsus alternans, tachycardia, gallop rhythms, and cardiac enlargement.

Moles is a common term used to identify which of the following? A. Nevi B. Striae C. Pimples D. Scars

A. Nevi Nevi, or moles, occur in forms that vary in size and degree of pigmentation. Nevi are present on most persons regardless of skin color and may occur anywhere on the body.

In which age group are milia an expected finding? A. Newborns B. Young children C. Adolescents D. Older adults

A. Newborns Milia are small, whitish, discrete papules on the face; they are commonly found during the first 2 to 3 months of life. The sebaceous glands function in an immature fashion at this age and are easily plugged by sebum. Answers b, c, and d are incorrect.

When assessing the lymph nodes of the head, which nodes do you palpate first? A. Occipital B. Preauricular C. Postauricular D. Retropharyngeal

A. Occipital Feel for nodes on the head in the following six-step sequence: (1) occipital nodes at the base of the skull; (2) postauricular nodes located superficially over the mastoid process; (3) preauricular nodes just in front of the ear; (4) parotid and retropharyngeal (tonsillar) nodes at the angle of the mandible; (5) submandibular nodes halfway between the angle and the tip of the mandible; (6) submental nodes in the midline behind the tip of the mandible.

Mrs. Handler is a 72-year-old woman with severe dementia and osteoarthritis. What tool would you use in assessing her pain? A. PAINAD Scale B. FLACC Behavioral Pain Assessment C. The Painometer D. Visual Analog Scale

A. PAINAD Scale Mrs. Handler has severe dementia and may not be able to describe her pain, including intensity. The PAINAD tool has good validity and reliability for scoring pain behaviors in older adults with dementia and the inability to communicate (see Fig. 4.13) (Paulson, Monroe, and Mion, 2014). The Painometer and Visual Analog Scale measure pain intensity, while the FLACC Behavioral Pain Assessment Scale is used to assess nonverbal children.

Mrs. Doh presents to your office with her 7-year-old son. Because of his religion, he has not had routine immunizations. You are concerned that he has mumps. Which of the following would help differentiate mumps from cervical adenitis? A. Palpating the angle of the jaw B. Palpating enlarged lymph nodes C. Noting painful lymph nodes D. Noting swelling of the face

A. Palpating the angle of the jaw Mumps, epidemic parotitis, is characterized by a somewhat painful swelling of the parotid glands unilaterally or bilaterally and, occasionally, by swelling and tenderness of the other salivary glands along the mandible. The swelling can obscure the angle of the jaw and may appear on inspection as a cervical adenitis. On palpation, however, the two are easily distinguished. A cervical adenitis does not ordinarily obscure the angle of the jaw. Your fingers can separate the node from the angle so that you can feel the hard sharpness of the bone, a finding generally not associated with parotid swelling.

Mr. Jones brings his child into your clinic for her kindergarten physical. On assessment, you note a jugular venous hum. You are aware that this can be confused with which abnormality? A. Patent ductus arteriosis B. Ventrical septal defect C. Coarctation of the aorta D. Pediatric hypertension

A. Patent ductus arteriosis A venous hum, common in children, usually has no pathologic significance. The venous hum can be confused with patent ductus arteriosus, aortic regurgitation, and the murmur of valvular aortic stenosis transmitted into the carotid arteries.

Mr. Lynch is a 46-year-old man who presents to your office for a routine examination. On examination of the corneal light reflex, you notice that there is asymmetry of the reflected light. What should your next step be? A. Perform the cover-uncover test. B. Test EOMs. C. Test for accommodation. D. Evaluate the depth of the anterior chamber.

A. Perform the cover-uncover test. An asymmetric light reflex may indicate a true strabismus or hypertelorism. If you find an imbalance with the corneal light reflex test, perform the cover-uncover test or use a strabismoscope or photoscreening to evaluate.

Mrs. Xavier is a 45-year-old patient who presents to your office with a complaint of a rash. On examination, you find a herald patch (round plaque with fine superficial scaling). Which of the following conditions identifies this finding? A. Pityriasis rosea B. Dermatophytosis C. Rosacea D. Herpes zoster

A. Pityriasis rosea Pityriasis rosea is a self-limiting inflammation of unknown cause. The herald lesion is commonly missed, although the most common sign of this condition.

A baby's height, until 2 years of age, is measured by: A. the recumbent length. B. stadiometer. C. height weight parameters. D. skinfold thickness.

A. the recumbent length. Measure the length of infants between birth and 24 months of age in supine position on a measuring device. Answers b, c, and d are false.

Mr. Torres is a 62-year-old patient who presents to your office with complaints of shortness of breath and dyspnea on exertion. On examination, you are unable to palpate the apical pulse. In addition, the heart sounds are very faint on auscultation. What condition should be considered? A. Pleural or pericardial fluid B. Congestive heart failure C. Mitral valve regurgitation D. Atrial septal defect

A. Pleural or pericardial fluid The absence of a visible, palpable apical impulse in addition to faint heart sounds, particularly when the patient is in the left lateral recumbent position, suggests some intervening extracardiac problem, such as pleural or pericardial fluid.

Milia in the newborn are caused by which of the following? A. Plugged sebaceous glands B. Inflammation of the sebaceous glands C. Plugged apocrine glands D. Overactive eccrine glands

A. Plugged sebaceous glands Milia are small whitish, discrete papules on the face; they are commonly found during the first 2 to 3 months of life. The sebaceous glands function in an immature fashion at this age and are easily plugged by sebum.

Which of the following best describes the beginning of ventricular contraction? A. Pressure in the ventricle forces atrioventricular valves to close. B. Ventricular contraction is initiated at the Purkinje point and proceeds in concentric circles around the ventricles. C. Pressure in the ventricles forces semilunar valves to close. D. Ventricular contraction is initiated within the myocardial septum and is transmitted vertically from the endocardium to the epicardium.

A. Pressure in the ventricle forces atrioventricular valves to close. As systole begins, ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valves closed, preventing backflow. This valve closure produces the first heart sound (S1), the characteristic "lubb." The intraventricular pressure rises until it exceeds that in the aorta and pulmonary artery. Then the aortic and pulmonic valves are forced open, and ejection of blood into the arteries begins. Valve opening is usually a silent event.

Mrs. Jones presents to your office for a complaint of visual disturbances. On examination, you note an abnormal growth of conjunctiva from the limbus over the cornea. Which term best describes this condition? A. Pterygium B. Arcus limbus C. Xanthelasma D. Episcleritis

A. Pterygium A pterygium is an abnormal growth of conjunctiva that extends over the cornea from the limbus. It occurs more commonly on the nasal side but may arise temporally as well. A pterygium is more common in people heavily exposed to ultraviolet light. It can interfere with vision if it advances over the pupil.

Which of the following indicates the correct method when performing mediate percussion? [plexor = striking finger; pleximeter = stationary finger] A. Remove the plexor immediately after contact with the pleximeter. B. Use forearm motion to cause the plexor to strike the pleximeter. C. Use the dominant hand as the pleximeter. D. Strike the pleximeter quickly with three blows of the plexor to obtain the best sounds.

A. Remove the plexor immediately after contact with the pleximeter. In this technique, the finger of one hand acts as the hammer (plexor) and a finger of the other hand acts as the striking surface. To perform indirect percussion, place your nondominant hand on the surface of the body with the fingers slightly spread. Place the distal phalanx of the middle finger firmly on the body surface with the other fingers slightly elevated off the surface. Snap the wrist of your other hand downward, and with the tip of the middle finger sharply tap the interphalangeal joint of the finger that is on the body surface (Fig. 3.1).

Which interviewer action is least appropriate when a patient engages in excessive flattery? A. Respond warmly and intimately. B. Remain calm, firm, and direct. C. Recognize that flattery can be manipulative. D. Ignore the patient's behavior.

A. Respond warmly and intimately. Responding warmly and intimately is inappropriate. Avert it courteously and firmly, delivering the immediate message that the relationship is and will remain professional. It takes skill to do this while maintaining the patient's dignity, but there is no room for sexual misconduct in the relationship, and there can be no tolerance for exploitation of the patient in this regard.

You are completing a fundoscopic examination on a 28-year-old patient. When examining the right eye with the ophthalmoscope, the examiner should use which hand to hold the ophthalmoscope? A. Right B. Left C. Dominant D. Nondominant

A. Right When using the ophthalmoscope, examine the patient's right eye with your right eye and the patient's left eye with your left. Hold the ophthalmoscope in the hand that corresponds to the examining eye.

Mr. Black is a 62-year-old patient who presents to your office for routine examination. You note a prominent jugular vein with significant pulsations. Which problem is consistent with this finding? A. Right-sided heart failure B. Hypertension C. Cardiac ischemia D. Left ventricular hypertrophy

A. Right-sided heart failure The jugular veins, which empty directly into the superior vena cava, reflect the activity of the right side of the heart and offer clues to its competency. The level at which the jugular venous pulse is visible gives an indication of right atrial pressure. With right-sided heart failure, jugular veins may be more visible.

Which of the following should be used to test for near vision in a 50-year-old patient? A. Rosenbaum Pocket Vision Screener B. Snellen "E" chart C. Confrontation test D. Landolt C

A. Rosenbaum Pocket Vision Screener Measurement of near vision should be tested in each eye separately with a handheld card such as the Rosenbaum Pocket Vision Screener.

Which finding in a 3-year-old child suggests an obstructive lung disease such as cystic fibrosis? A. Round chest B. Distant breath sounds C. Barking cough D. Abdominal breathing

A. Round chest If the roundness of the young child's chest persists past the second year of life, be concerned about the possibility of a chronic obstructive pulmonary problem such as cystic fibrosis.

A patient with which lifestyle characteristic is at risk for respiratory disability? A. Severe obesity B. Exposure to ultraviolet lights in the office setting C. Rigorous daily exercise routine D. Increased dietary fiber intake

A. Severe obesity Extreme obesity is a characteristic that serves as a barrier to competent functioning.

When auscultating the lungs, which of the following sequences should be used? A. Side to side comparison, from apex to base B. Front to back comparison, from apex to base C. Listen to the right lung first, apex to base, then the left lung apex to base D. Listen to the right lung during inspiration, the left lung during expiration, from apex to base

A. Side to side comparison, from apex to base When auscultating the lungs, listen systematically at each position throughout inspiration and expiration, taking advantage of a side-to-side comparison as you move downward from apex to base at intervals of several centimeters. The sounds of the middle lobe of the right lung and the lingula on the left are best heard in the respective axillae.

An excess proportion of trunk and abdominal fat is associated with higher risk for which of the following? A. Stroke B. Cushing syndrome C. Hypopituitary dwarfism D. None of the above

A. Stroke An excess proportion of trunk and abdominal fat (e.g., an ovoid or apple-shaped body) has a higher risk association with diabetes, dyslipidemia, metabolic syndrome, stroke, and ischemic heart disease than does a greater proportion of gluteal fat (e.g., a pear-shaped body).

Which is the first sign of a boy starting puberty? A. Testicular enlargement B. Apperance of pubic hair C. Enlargement of the penis D. Occurrence of nocturnal emissions

A. Testicular enlargement Most boys start puberty between 10 and 13 years of age with testicular enlargement. Answers b, c, and d follow testicular enlargement.

The sebaceous gland secretes sebum primarily in response to which of the following hormones? A. Testosterone B. Estrogen C. Progesterone D. Growth hormone

A. Testosterone The sebaceous glands secrete sebum, a lipid-rich substance that keeps the skin and hair from drying out. Secretory activity, which is stimulated by sex hormones (primarily testosterone), varies according to hormonal levels throughout the life span.

Which statement best describes the chest of a newborn? A. The anteroposterior (AP) diameter is about equal to the lateral diameter. B. The transverse diameter is greater than the AP diameter. C. The AP diameter approximates the circumference. D. The AP diameter is greater than the circumference of the head.

A. The anteroposterior (AP) diameter is about equal to the lateral diameter. The chest of the newborn is generally round, the AP diameter approximating the lateral diameter, and the circumference is roughly equal to that of the head until the child is about 2 years old.

How does the carotid pulse different from the jugular pulse? A. The arterial pulse can be palpated, whereas the venous pulse is visualized. B. The arterial pulse contains both systolic and diastolic components, whereas the venous pulse only has a systolic component. C. The venous pulse has an a, c, and v wave, and the arterial pulse has an x, y, and z wave. D. The venous pulse is a reflection of pulmonary circulation, and the arterial pulse is a reflection of systemic circulation.

A. The arterial pulse can be palpated, whereas the venous pulse is visualized. The jugular pulse is a venous pulse and can only be visualized; it cannot be palpated. The carotid is an arterial pulse and can be palpated.

Which of the following is true regarding the correct use of a stethoscope? A. The bell is pressed lightly against the skin to detect low-frequency sounds. B. The bell is pressed firmly against the skin to hear low-frequency sounds. C. The diaphragm is pressed firmly against the skin to hear low-frequency sounds. D. The diaphragm is pressed lightly against the skin to hear high-frequency sounds.

A. The bell is pressed lightly against the skin to detect low-frequency sounds. Because the bell functions by picking up vibrations, it must be positioned so that the vibrations are not dampened. Place the bell evenly and lightly on the skin, making sure there is skin contact around the entire edge.

Mr. Harris is a 67-year-old patient who presents to your office with a complaint of hearing loss. On examination, you perform the Weber test. Which of the following is considered a normal finding? A. The patient hears the tone equally in both ears. B. The patient hears the tone better in one ear than in the other. C. The patient hears sounds longer when conducted through air than when conducted through bone. D. The patient is able to detect tones of varying frequencies and pitches from a tuning fork.

A. The patient hears the tone equally in both ears. The Weber test helps assess unilateral hearing loss. The patient should hear the sound equally in both ears.

Mrs. Gorski is a 38-year-old patient who is 8 months pregnant and presents to your office for a routine visit. Which of the following cardiovascular findings would be considered normal for Mrs. Gorski? A. The position of the heart shifts up and to the left; the apex moves laterally. B. Percussion reveals a decrease in left ventricular size. C. Assessment of the lower legs reveals 3+ pitting edema. D. Blood pressure is 150/118.

A. The position of the heart shifts up and to the left; the apex moves laterally. The heart position is shifted during pregnancy, but the position varies with the size and position of the uterus. The apical impulse is upward and more lateral by 1 to 1.5 cm. Expect some changes in auscultated heart sounds because of the increased blood volume and extra effort of the heart. As the uterus enlarges and the diaphragm moves upward in pregnancy, the position of the heart is shifted toward a horizontal position, with slight axis rotation.

Mrs. Tanker is a 62-year-old patient who presents to your office with a complaint of chest pain. On cardiac auscultation, you note a split heart sound. What is the physiologic basis of a split sound? A. The right side of the heart contracts later than the left side. B. The atria contract later than the ventricles. C. The ventricles contract later than the atria. D. The atria contract before the ventricles.

A. The right side of the heart contracts later than the left side. The events of the cardiac cycle are not exactly identical on both sides of the heart. In fact, pressures in the right ventricle, right atrium, and pulmonary artery are lower than the left side of the heart; and the same events occur slightly later on the right side than on the left. The effect is that heart sounds sometimes have two distinct components, the first produced by the left side and the second by the right side. For example, the aortic valve closes slightly before the pulmonic, so that S2 is often heard as two distinct components, referred to as "split S2" (A2, then P2). Splitting occurs when the mitral and tricuspid valves or the pulmonic and aortic valves do not close simultaneously.

Which finding is most likely to cause an examiner to suspect a foreign object in the nose of a young child? A. There is a purulent discharge from the child's nose. B. The turbinates appear bluish gray and boggy. C. The child cries when the soft tissue of the nose is palpated. D. Unilateral nasal flaring is present.

A. There is a purulent discharge from the child's nose. Purulent discharge may be associated with an upper respiratory infection, sinusitis, or a foreign body.

Marrow-derived cells are further differentiated to T lymphocytes in which part of the lymph system? A. Thymus B. Spleen C. Tonsils D. Peyer patches

A. Thymus Marrow-derived cells that mature in the thymus (T lymphocytes) are further differentiated into types of T cells, each with a distinct function. A unique feature of T cells is their ability to discriminate between healthy and abnormal cells. Activation by their specific antigen (e.g., a living virus, bacterium, parasite, chemical, malignant change) elicits an immune response. T lymphocytes also have an important role in controlling the immune responses brought about by B lymphocytes.

Which of the following statements is an accurate interpretation of the balance of "hot" and "cold"? A. Treatment to restore "hot" and "cold" balance requires the use of opposites. B. The recommended treatment for a "cold" condition is to serve "cold" foods. C. The recommended treatment for a "hot" condition is "hot" foods and "cold" medications. D. Ailments and treatments considered to be "hot" or "cold" are related to the effect of body temperature.

A. Treatment to restore "hot" and "cold" balance requires the use of opposites. The balance of "hot" and "cold" is a naturalistic or holistic approach and often assumes that there are external factors—some good, some bad—that must be kept in balance if we are to remain well. To restore a disturbed balance—that is, to treat—requires the use of opposites (e.g., a "hot" remedy for a "cold" problem and vice versa). Different cultures may define "hot" and "cold" differently. Answers b, c, and d do not represent this theory.

To be culturally aware is to understand those aspects of the human condition that differentiate individuals and groups. A. True B. False

A. True Cultural awareness is the deliberate self-examination and in-depth exploration of the biases, stereotypes, prejudices, assumptions, and "isms" that we hold about individuals and groups who are different from ourselves.

Culture is influenced by family structure and social organizations, such as churches, clubs, and schools. A. True B. False

A. True Family structure and the social organizations to which a patient belongs (e.g., faith-based organizations, clubs, and schools) are among the many imprinting and constraining cultural forces.

Personalized medicine refers to the consideration of an individual's genetic endowment in the context of environmental influences when providing health care. A. True B. False

A. True Personalized medicine, as defined by the National Cancer Institute, is "a form of healthcare that considers information about a person's genes, proteins and environment to prevent, diagnose and treat disease" (Su, 2013).

Poverty and inadequate education have a cultural impact that is seriously reflected in access to and use of health care. A. True B. False

A. True Racial and ethnic differences, as well as social and economic conditions, may affect the provision of specific health care services to certain groups and subgroups in the United States. Poverty and inadequate education disproportionately affect various cultural groups (e.g., ethnic minorities and women); socioeconomic disparities negatively affect the health and medical care of individuals belonging to these groups.

The Chinese describe the forces of "hot" and "cold" as yin and yang. A. True B. False

A. True The force of "hot" and "cold" is a part of the belief system in many cultural groups. Different cultures define "hot" and "cold" differently. For example, the Chinese have named the forces yin (cold) and yang (hot). No matter the name, it is the naturalistic view that we must recogonize to provide culturally appropriate care.

It is important to use the same scale for assessment of pain throughout a patient's episode of illness. A. True B. False

A. True Using the same scale promotes consistency in the assessment and evaluation of interventions to address the pain. If all providers use the same set of pain scales, more consistent interpretation of patient pain ratings is likely to occur.

An individual may and probably does belong to more than one group or subgroup. A. True B. False

A. True Within the cultural whole, different populations may exist in groups and subgroups. Each group is identified by a particular body of shared traits (e.g., a particular art, ethos, or belief or a particular behavioral pattern) and rather dynamic in its evolving accommodations with internal and external influences. Any individual may belong to more than one group or subgroups, such as ethnic origin, religion, gender, sexual orientation, occupation, and profession.

Which is the loudest percussion tone? A. Tympany B. Hyperresonance C. Dullness D. Flatness

A. Tympany Tympany is one of the degrees of percussion tones. Tympany is the loudest of them all.

What is the red pulp of the spleen? A. Venous sinusoids B. Recycled hemoglobin C. Clustered lymphoid nodules D. Activated antigen tissue

A. Venous sinusoids The spleen is a highly vascular organ. It is composed of two systems: (1) the white pulp, made up of lymphatic nodules and diffuse lymphatic tissue, and (2) the red pulp, made up of venous sinusoids.

Which type of breath sounds are normally auscultated over most of the lung fields? A. Vesicular B. Bronchovesicular C. Bronchial D. Tubular

A. Vesicular Vesicular breath sounds are low-pitched, low-intensity sounds heard over healthy lung tissue. They are heard over most of lung fieldsm, they are low-pitched, soft and short expirations.

Other than for use with pediatric patients, when might it be appropriate to use a pediatric blood pressure cuff? A. When an adult patient is thin B. When the patient is older than 90 years of age C. When the Korotkoff sounds are inaudible D. When serial blood pressures are to be taken

A. When an adult patient is thin Thin adult patients may require the use of a pediatric blood pressure cuff. When a cuff is used that is too large, blood pressure may be underestimated.

The persistence of a round "barrel" chest in a child past the second year of life may be indicative of: A. a chronic obstructive problem, such as cystic fibrosis. B. delayed growth and development. C. an immature pulmonary system. D. the possibility of developing pectus carinatum.

A. a chronic obstructive problem, such as cystic fibrosis. If the roundness of the young child's chest persists past the second year of life, be concerned about the possibility of a chronic obstructive pulmonary problem such as cystic fibrosis. The persistence of a barrel chest at the age of 5 or 6 years can be ominous.

A history of an individual's food intake is important because it: A. allows estimation of the adequacy of the diet. B. identifies foods from the food pyramid. C. compares the recommended dietary allowances to the US Department of Agriculture food pyramid. D. compares diet and exercise.

A. allows estimation of the adequacy of the diet. The history of an individual's food and beverage intake allows estimation of the adequacy of the diet. Histories may be obtained through 24-hour diet recalls or with a 3- or 4-day food diary that includes 1 weekend day. Various methods for measuring nutrient intake are available.

S3 and S4 become a major concern when accompanied by: A. an increase in intensity. B. an increase in heart rate. C. a decrease in blood pressure. D. a decreased intensity of S1 and S2.

A. an increase in intensity. S3 and S4 may or may not be present. Their absence is not an unusual finding, and their presence does not necessarily indicate a pathologic condition. Thus, evaluate S3 and S4 in relation to other sounds and events in the cardiac cycle. A loud S4 always suggests a pathologic condition and deserves additional evaluation. Increased intensity of either sound is suspect.

Mr. Charles is a 38-year-old patient who presents to your office with a complaint of fatigue and a family history of hypothyroidism. As the examiner palpates an enlarged lymph node, the patient complains of pain. This is an indication of: A. an inflammatory process. B. Hodgkin disease. C. immature lymph node development. D. malignancy.

A. an inflammatory process. When examining nodes, the examiner is reminded that, the more tender a node, the more likely it is an inflammatory process.

Periodic breathing is characterized by intervals of respiration separated by periods of: A. apnea. B. hyperpnea. C. hypopnea. D. eupnea.

A. apnea. Apnea, the absence of spontaneous respiration, may have its origin in the respiratory system and, as well, in a variety of central nervous system and cardiac abnormalities.

Wrinkling of the skin is less marked in individuals who: A. are obese. B. demonstrate premature graying. C. are white. D. have overactive sebaceous and sweat gland activity.

A. are obese. Obese individuals have more subcuatenous fat. A wrinkled appearance is the result of the dermis becoming less elastic, a loss of collagen and elastic fibers, and shrinkage. A lifetime of exposure to the sun also predisposes the skin to wrinkling.

Atelectasis is a condition that occurs: A. at any age. B. mostly during childbirth. C. rarely in older adults. D. strictly from tuberculosis.

A. at any age. Atelectasis is the incomplete expansion of the lung at birth or the collapse of the lung at any age.

Interviewers should identify and assess their own feelings, such as hostility and prejudice, in order to: A. avoid inappropriate behavior. B. explain their biases to patients. C. express personal idiosyncrasies. D. promote self-awareness.

A. avoid inappropriate behavior. Your own beliefs, attitudes, and values cannot be discarded, but you do have to discipline them. You have to be aware of your cultural beliefs, faith, and conscience so that they do not inappropriately intrude as you discuss with patients a variety of issues. That means knowing yourself. You will better control possible barriers to a successful outcome.

The third intercostal space is located: A. between the third and fourth rib. B. between the second and third rib. C. 3 inches down from the clavicle. D. just below the third rib below the clavicle.

A. between the third and fourth rib. The number of each intercostal space corresponds to that of the rib immediately above it.

Mrs. Jones is a 45-year-old patient with asthma who presents to your office. On examination, chest movement can best be seen with: A. bright tangential lighting. B. daylight from a window. C. a flashlight in a dark room. D. fluorescent ceiling lights.

A. bright tangential lighting. When examining the chest, having a bright tangential light is needed to highlight chest movement.

A skin lesion that may be associated with neurofibromatosis or pulmonary stenosis is: A. café au lait spots. B. nevus vasculosus. C. port wine limb stain. D. spider angioma.

A. café au lait spots. Café au lait spots are flat, evenly pigmented spots varying in color from light brown to dark brown or black on dark skin, are larger than 5 mm in diameter, and are present at birth or shortly thereafter. They may be associated with neurofibromatosis or miscellaneous other conditions, including pulmonary stenosis, temporal lobe dysrhythmia, and tuberous sclerosis.

Decrease in pulmonary pressure as a result of the relaxation and expansion of the pulmonary arteries at birth causes: A. closure of the foramen ovale. B. hyperinflation of the lungs. C. passive respiratory movements. D. reopening of the ductus arteriosus.

A. closure of the foramen ovale. This relative decrease in pulmonary pressure most often leads to closure of the foramen ovale within minutes after birth, and the increased oxygen tension in the arterial blood usually stimulates contraction and closure of the ductus arteriosus (see Clinical Pearl, "Patent Ductus Arteriosus [PDA]").

An ophthalmoscope has positive and negative magnification to: A. compensate for myopia or hyperopia in the examiner's or the patient's eyes. B. allow for magnification of both the anterior eye and the posterior eye. C. compensate for the degree of dilation of the patient's eyes. D. allow for visualization of the eye in patients with normal vision, as well as those with glaucoma.

A. compensate for myopia or hyperopia in the examiner's or the patient's eyes. The ophthalmoscope shows the expected lens diopters to focus on eye structures. The system of plus and minus lenses can compensate for myopia or hyperopia in both the examiner and the patient. There is no compensation for astigmatism.

A woman presents to a women's health clinic stating that she has had a positive home pregnancy test and desires prenatal care. You would conduct a(n): A. complete history. B. focused history. C. problem-oriented history. D. interim history.

A. complete history. The examiner would conduct a complete history because the complete history allows the examiner to become thoroughly familiar with the patient. Most often, this history is recorded the first time you see the patient. The other answers are used when something is already known about the patient or an established relationship exists.

A tympanic membrane that is retracted is also more: A. concave. B. convex. C. impacted. D. dilated.

A. concave. A retracted tympanic membrane is more concave, usually with accentuated bony landmarks and a distorted light reflex.

Changes in clarity and volume of spoken sounds during auscultation of the lungs can help you distinguish: A. consolidation from obstruction. B. foreign body from mucous. C. pulmonary edema from pleurisy. D. right from left tracheal deviation.

A. consolidation from obstruction. Greater clarity and increased loudness of spoken sounds are defined as bronchophony. If bronchophony is extreme (e.g., in the presence of consolidation of the lungs), even a whisper can be heard clearly and intelligibly through the stethoscope (whispered pectoriloquy).

An integral part of the overall effort to adequately respond to a person in need is: A. cultural awareness. B. ethnocentric bias. C. political correctness. D. racial alertness.

A. cultural awareness. Cultural awareness is the deliberate self-examination and in-depth exploration of the biases, stereotypes, prejudices, assumptions, and "isms" that we hold about individuals and groups who are different from ourselves.

The color of the nasal mucosa should appear: A. deep pink. B. red. C. bluish gray. D. pale pink.

A. deep pink. Expect the nasal mucosa to glisten and appear deep pink (pinker than the buccal mucosa).

A gradual symmetric hair loss in males during adulthood occurs as response to: A. elevated androgen levels. B. overactive sebaceous glands in the scalp. C. endocrine disorders. D. decreased circulation/nutritional deficiencies.

A. elevated androgen levels. Hair production is one response to changing androgen levels. Genetically predisposed men often display a gradual symmetric hair loss on the scalp during adulthood as a response to androgens. Asymmetric hair loss may indicate a pathologic condition.

Percussion of the back should be done with the patient's arms folded in front in order to: A. expose maximum lung area. B. make the scapulae protrude. C. prevent attacks of coughing. D. recognize thudlike sounds.

A. expose maximum lung area. To auscultate the back, ask the patient to sit as for percussion, with head bent forward and arms folded in front. Sitting moves the scapula laterally exposing more of the lung.

Typically, an infant's weight, height (length), and _______________ are routinely measured to assess and monitor growth. A. head circumference B. hip-to-toe length C. forearm length D. chest circumference

A. head circumference A newborn's fetal growth pattern and size for gestational age can be determined once gestational age is assigned. An intrauterine growth curve is used to plot the newborn's birth weight, length, and head circumference (see Evolve website for growth curves). The infant is then classified as small, appropriate, or large for gestational age by percentile curve placement for weeks of gestation.

The OLDCARTS mnemonic is a guide to the: A. history of the present illness. B. review of systems. C. family history. D. personal and social history.

A. history of the present illness. The OLDCARTS mnemonic helps make sure all characteristics of a problem are described in the history of present illness to ensure a comprehensive presentation.

Intensity in relation to percussion tones refers to: A. how loud the tone is. B. the location of the tone. C. the musical quality of the tone. D. the length of duration the tone is heard.

A. how loud the tone is. The intensity of a percussion tone refers to its loudness as detailed in Table 3.3.

Mrs. Troba is a 68-year-old patient who presents to your office with a complaint of elevated blood pressure. In older individuals, blood pressure tends to become elevated as a result of: A. increased peripheral vascular resistance. B. increased heart rate. C. increased cardiac output. D. significant electrocardiographic (ECG) changes.

A. increased peripheral vascular resistance. Calcification and plaque buildup in the walls of the arteries can cause stiffness as well as dilation of the aorta, aortic branches, and the carotid arteries. The arterial walls lose elasticity and vasomotor tone and are less distensible. The resulting increased peripheral vascular resistance may lead to elevated blood pressure, especially systolic.

Saliva, which is secreted by the salivary glands, is responsible for moisturizing the mucosa and: A. initiating digestion. B. providing adhesion for food nutrients. C. stimulating glutition. D. facilitating identification of taste.

A. initiating digestion. The parotid, submandibular, and sublingual salivary glands are located in tissues surrounding the oral cavity. The secreted saliva initiates digestion and moistens the mucosa.

The examiner notes a large blue-black spot on the buttock of a 4-week-old black neonate. The mother states that the infant was born with it. The examiner should recognize that this: A. is an expected finding. B. may indicate child abuse. C. is related to birth trauma. D. suggests a congenital defect.

A. is an expected finding. This finding is indicative of Mongolian spots. Mongolian spots are irregular areas of deep blue pigmentation, usually in the sacral and gluteal regions, and are seen predominantly in newborns of African, Native American/American Indian, Asian, or Latin descent. They commonly appear on the back, buttocks, shoulders, and legs of well babies and usually disappear in the preschool years.

Mrs. Carter has vision that at best is 20/210. Mrs. Carter is considered: A. legally blind. B. mildly myopic. C. moderately hyperopic. D. unilaterally anisocoric.

A. legally blind. The smaller the fraction, the worse is the vision. Vision not correctable to better than 20/200 is considered legal blindness.

During assessment of vocal resonance, you note that sound is intensified, that there is a nasal quality to the voice, and that es sound like as. This is indicative of: A. lung consolidation. B. emphysema. C. bronchial obstruction. D. asthma.

A. lung consolidation. Greater clarity and increased loudness of spoken sounds are defined as bronchophony. If bronchophony is extreme (e.g., in the presence of consolidation of the lungs), even a whisper can be heard clearly and intelligibly through the stethoscope (whispered pectoriloquy).

A 6-year-old girl has freckles over her nose and cheeks. The examiner will recall that freckles are a type of: A. macule. B. papule. C. nodule. D. patch.

A. macule. A macule is a flat, circumscribed area that is a change in the color of the skin usually less than 1 cm in diameter. Freckles, flat moles, petechiae, and measles are examples of macules.

For structures that have a round shape, such as the tympanic membrane, an effective way to document location of an alteration is to relate its location to the: A. numbers on the face of a clock. B. degrees in a circle. C. divisions on a chronometer. D. spokes on a wheel.

A. numbers on the face of a clock. In some cases, location of a finding on or near a specific structure (e.g., tympanic membrane, rectum, vaginal vestibule) may be described by its position on a clock.

Mrs. Harris is a 46-year-old patient who presents to your office for a routine physical examination. During the history and physical, you note expected Rinne and Weber test results. This would be documented: A. objective data. B. subjective data. C. systematic data. D. functional data.

A. objective data. Objective data are the findings resulting from direct observation—what you see, hear, and touch. Record the objective data by body systems and anatomic location.

Retractions are generally associated with: A. obstruction to inspiration. B. increased respiratory rate. C. abdominal breathing. D. thoracic breathing.

A. obstruction to inspiration. Retractions are seen when the chest wall seems to cave in at the sternum, between the ribs, at the suprasternal notch, above the clavicles, and at the lowest costal margins. This suggests an obstruction to inspiration at any point in the respiratory tract. As intrapleural pressure becomes increasingly negative, the musculature "pulls back" in an effort to overcome blockage. Any significant obstruction makes the retraction observable with each inspiratory effort.

While observing a patient's respirations, you note that, on inspiration, the lower thorax is drawn in and the abdomen protrudes. On expiration, the opposite occurs. This may be documented as: A. paradoxic breathing. B. Biot respiration. C. Kussmaul breathing. D. abdominal respiration.

A. paradoxic breathing. With paradoxic breathing, on inspiration the lower thorax is drawn in, and on expiration, the opposite occurs. This develops when negative intrathoracic pressure is transmitted to the abdomen by a weakened, poorly functioning diaphragm; obstructive airway disease; or during sleep, in the event of upper airway obstruction.

A "rubbing" that can be felt and heard is most closely associated with: A. pleurisy. B. pneumonia. C. emphysema. D. asthma.

A. pleurisy. Pleurisy is an inflammatory process involving the visceral and parietal pleura characterized by patients reporting subjective rubbing of the pleural surfaces.

Gingivitis is characterized by: A. redness and swelling of the margins of the gums. B. brownish melanin pigmentation of the gums. C. thick white patches on the mucous membranes. D. hypertrophy of the tongue.

A. redness and swelling of the margins of the gums. Easily bleeding, swollen gums with enlarged crevices between the teeth and gum margins, or pockets containing debris at tooth margins, are associated with gingivitis or periodontal disease

Mr. Webber is a 53-year-old patient who has a fixed split heart sound. Splitting is said to be fixed when it is unaffected by: A. respiration. B. stroke volume. C. blood pressure. D. heart rate.

A. respiration. Splitting is said to be fixed when it is unaffected by respiration. This occurs with delayed closure of the pulmonic valve when output of the right ventricle is greater than that of the left.

Which is the correct technique for performing a fundoscopic examination with a traditional ophthalmoscope? Examine the patient's: A. right eye with your right eye, and the left eye with your left eye. B. right eye with your left eye, and the left eye with your right eye. C. right and left eyes with your dominant eye. D. right and left eyes with your nondominant eye.

A. right eye with your right eye, and the left eye with your left eye. The ophthalmoscopic (fundoscopic) examination of the eyes can be a tiring process for the patient. Examine the patient's right eye with your right eye and the patient's left eye with your left. Hold the ophthalmoscope in the hand that corresponds to the examining eye.

The number of each intercostal space corresponds to that of: A. the rib immediately above it. B. the rib immediately below it. C. the number of centimeters it is positioned below the clavicle. D. the number of inches it is positioned below the clavicle.

A. the rib immediately above it. One can count the ribs and intercostal spaces from this point. The number of each intercostal space corresponds to that of the rib immediately above it.

The difference between a tuning fork for auditory screening and one for vibratory sensation is: A. the sound frequency generated. B. the strike force placed by the examiner on the forks. C. the length of the tuning forks. D. the auditory screening fork is electric; the vibratory fork is not.

A. the sound frequency generated. For auditory evaluation, use a fork with a frequency of 500 to 1000 Hz because it estimates hearing loss in the range of normal speech, approximately 300 to 3000 Hz. For vibratory sensation, use a fork of lower frequency. The greatest sensitivity to vibration occurs when the fork is vibrating between 100 and 400 Hz.

The external ear is separated from the middle ear by the: A. tympanic membrane. B. cochlea. C. organ of Corti. D. auditory ossicles.

A. tympanic membrane. The tympanic membrane, surrounded by a dense fibrous ring (annulus), separates the external ear from the middle ear. It is concave, being pulled in at the center (umbo) by the malleus. The tympanic membrane is translucent, permitting the middle ear cavity and malleus to be visualized.

The anterior triangle is located: A. under the mandible, medial to the sternocleidomastoid muscle. B. between the trapezius and sternocleidomastoid muscle. C. at the base of the clavicle. D. between the cricoid and thyroid cartilages.

A. under the mandible, medial to the sternocleidomastoid muscle. The anterior triangle is formed by the medial border of the sternocleidomastoid muscles, the mandible, and the midline. The posterior triangle is formed by the trapezius and sternocleidomastoid muscles and the clavicle and contains the posterior cervical lymph nodes.

Mr. Davids is a 48-year-old patient with high cholesterol and diabetes. Individuals with abnormal lipid metabolism are at risk for deposition of flat, slightly raised, irregularly shaped, yellow tinted lesions on the periorbital tissues that are called: A. xanthelasma. B. xanthophose. C. xanthophylls. D. xanthosis.

A. xanthelasma. When examining the surrounding structures, you may see flat to slightly raised, oval, irregularly shaped, yellow-tinted lesions on the periorbital tissues that represent depositions of lipids and may suggest that the patient has an abnormality of lipid metabolism. These lesions are called xanthelasma, an elevated plaque of cholesterol deposited in macrophages, most commonly in the nasal portion of the upper or lower lid.

Which question is most appropriate to ask a female patient with a suspected thyroid problem? A. "How much alcohol do you drink?" B. "Has your sleep pattern or energy level changed?" C. "Do you have morning headaches?" D. "Do you use birth control?"

B. "Has your sleep pattern or energy level changed?" A change in mood and energy, irritability, nervousness, lethargy, and disinterest are a few problems a patient with thyroid problems may have.

A patient with long-standing COPD has come to the clinic complaining that breathing has been getting more difficult over the last couple of weeks. Which question would best help the examiner understand the hypoxia a patient is experiencing? A. "Do you think oxygen will help you?" B. "In what way has your activity level been affected?" C. "Do you have a cough?" D. "Have you been taking your medications?"

B. "In what way has your activity level been affected?" Answer b helps the examiner understand the severity of the patient's shortness of breath.

Over a period of 3 years, the mother of three young children has repeatedly been instructed by the health care provider to get the children immunized; however, the children are still not immunized. The answer to which of the following questions would help the health care provider understand this situation? A. "When are you going to get your children immunized?" B. "What are your beliefs about immunizations?" C. "We have asked you to get your children immunized. Why has this not been done?" D. "Don't you understand that your children may get ill without immunizations?"

B. "What are your beliefs about immunizations?" Answer b is an example of a question that delves into the health beliefs and practices of the mother. Answers a, c, and d do not allow the mother to define her health and illness practices.

A young mother brings her infant to the emergency department with a high temperature and dehydration. Which of the following responses by the health care provider is inappropriate and fails to demonstrate cultural awareness? A. "How sick do you think your baby is?" B. "Why didn't you bring your baby in sooner?" C. "What do you think is causing this illness?" D. "What have you done at home to treat the baby's illness?"

B. "Why didn't you bring your baby in sooner?" Cultural awareness is the deliberate self-examination and in-depth exploration of the biases, stereotypes, prejudices, assumptions, and "isms" that we hold about individuals and groups who are different from ourselves. Answer b is a response that does not leave room for the mother to divulge her cultural beliefs or practices.

Which weight gain during pregnancy is in the recommended range for a woman whose BMI was 27.3 prepregnancy? A. 28½ lbs B. 17½ lbs C. 14 lbs D. 9 lbs

B. 17½ lbs Guidelines for recommended weight gain during pregnancy are based on the woman's prepregnancy BMI to improve reproductive outcomes. Overweight women (BMI 26.1 to 29) should gain 7 to 11.5 kg (15 to 25 pounds). Those who are obese (BMI greater than 29) should gain no more than 5 to 9.1 kg (11 to 20 pounds) (Institute of Medicine and National Research Council, 2009).

The examiner should expect the ratio of respiratory rate to heart rate to be approximately: A. 1:2. B. 1:4. C. 1:6. D. 1:8.

B. 1:4. Determine the respiratory rate. The rate should be 12 to 20 respirations per minute; the ratio of respirations to heartbeats is approximately 1:4.

A neonate was 18½ inches long at birth. What would you expect his length to be at age 1 year? A. 24 to 25 inches B. 27¾ inches C. 30 to 31 inches D. 37 inches

B. 27¾ inches At birth, healthy term newborns have length variations between 45 and 55 cm (18 and 22 inches). Length increases by 50% in the first year of life (18.5/2 + 9.25 = 27.75).

The prevalence of obesity among adults is increasing. In 2010 in the United States, what was the percentage of obese adults? A. 15.5% B. 35.7% C. 49% D. 65.2%

B. 35.7% Obese children often become obese adults. In 2010, 35.7% of adults in the United States were obese (Center for Disease Control Division of Nutrition, Physical Activity, and Obesity, 2012).

The apex of the lung is: A. even with the second rib. B. 4 cm above the first rib. C. higher on the right side. D. on the convex diaphragm surface.

B. 4 cm above the first rib. Each lung apex is rounded and extends anteriorly about 4 cm above the first rib into the base of the neck in adults. Posteriorly, the apices of the lungs rise to about the level of T1.

In the older adult patient, stature begins to decline at: A. 40 years of age. B. 50 years of age. C. 60 years of age. D. 70 years of age.

B. 50 years of age. Physical stature declines in older adults beginning at approximately 50 years of age. The intervertebral disks thin, and kyphosis develops with osteoporotic vertebral compression.

Which assessment finding is consistent with thyroid disease? A. A history of bacterial infection B. A change in texture of the hair, skin, or nails C. Hemianopia D. Pain with swallowing

B. A change in texture of the hair, skin, or nails A change in hair texture, skin, or nails is associated with thyroid problems.

Which of the following correctly describes lineal cultural value orientation? A. Interpersonal relationships are subject to the environment. B. A son's goals are not as important as his father's. C. Outside social relationships are more important than family. D. Expression of self is the individual's main goal.

B. A son's goals are not as important as his father's. In relational orientation, lineal cultural value orientation occurs as group goals dominant over individual goals. They are ordered by positional succession.

During a health history, your patient describes having experienced aimless, jerky movements, episodes of shortness of breath, and chest pain. With which disease are these symptoms associated? A. Heart failure B. Acute rheumatic fever C. Hypertension D. Atrial stenosis

B. Acute rheumatic fever Rhuematic fever is a systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection characterized by unexplained fever, swollen joints, aimeless jerky movements (Sydenham chorea/St. Vitus dance), abdominal pain, skin rash (erythema marginatum), or nodules. Additional subjective symptoms may include shortness of breath, chest pain, palpitations, and a flat or slightly raised rash that is painless in nature.

Cultural groups have different value orientations. Choose the statement that best reflects the past-oriented value orientation. A. A diabetic patient believes that the reason he has diabetes is because of his past eating habits. B. An Asian woman with cancer sees her herbalist for treatment. C. People who have come from a low socioeconomic status have fewer health problems. D. Environmental factors are the rationale behind past value choices.

B. An Asian woman with cancer sees her herbalist for treatment. Answer b is the best choice. Past-oriented value orientation cultures maintain traditions that were meaningful in the past and/or worship ancestors.

How is a patient classified who has a body mass index (BMI) of 24.8? A. Undernurished B. Appropriate weight for height C. Overweight D. Obese

B. Appropriate weight for height The BMI is the most common method used to assess nutritional status and total body fat. A BMI of 18.5 to 24.9 is the appropriate weight and height. Answers a, c, and d have different BMIs associated with their meaning.

When testing the pupil for accommodation, which of the following results would be expected? A. As the individual focuses on a distant object, the pupils constrict. B. As the individual focuses on a close object, the pupils constrict. C. As the patient focuses on a distant object, the pupils diverge. D. As the patient focuses on a close object, the pupils converge.

B. As the individual focuses on a close object, the pupils constrict. To test the pupillary respnse to accommodation ask the patient to look at a distant object and then at a test object (either a pencil or your finger) held 10 cm from the bridge of the nose. Expect the pupils to constrict when the eyes focus on the near object. With some patients, especially those with dark irides, it may be easier to observe pupillary dilation when the patient looks from near to far.

Mrs. Harold is a 36-year-old patient who presents to your office with a complaint of visual disturbances. As part of her eye examination, you assess for pupillary response to accommodation. Which method would you use? A. Shine a light into the pupil; note constriction. B. Ask the patient to shift her gaze from across the room to an object 6 inches away; note pupillary constriction. C. Ask the patient to follow an object through the six cardinal fields of gaze; note ocular movement. D. Cover one of the patient's eyes with a card; remove the card and note any deviation from a fixed gaze.

B. Ask the patient to shift her gaze from across the room to an object 6 inches away; note pupillary constriction. To test the pupillary response to accommodation ask the patient to look at a distant object and then at a test object (either a pencil or your finger) held 10 cm from the bridge of the nose. Testing for pupillary response to accommodation is of diagnostic importance only if there is a defect in the pupillary response to light. A failure to respond to direct light but retaining constriction during accommodation is sometimes seen in patients with diabetes or syphilis.

Which condition is characterized by hyperresonance and a prolonged expiratory effort? A. Asthma B. Emphysema C. Pneumonia D. Pneumothorax

B. Emphysema Emphysema is a condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function. When percussed, the examiner will find hyperresonance and auscultate diminished breath sounds, as well as prolonged expiration.

Which is a true statement about lymphatic tissue? A. The number of adipose cells affects development of lymph tissue. B. At 10 to 12 years of age, lymph tissue is at its peak. C. Lymphatic tissues are completely developed by 6 years of age. D. During adolescence, lymphatic tissues increase in size.

B. At 10 to 12 years of age, lymph tissue is at its peak. Lymph nodes, spleen, tonsils, adenoids, and blood lymphocytes constitute lymph tissue. These tissues grow rapidly to reach adult size by 6 years of age but peak and double the adult size between 10 to 12 years of age.

Mrs. Jones is a 55-year-old patient who returns to your office today for a follow-up examination. You suspect that she has an arterial aneurysm. Which examination technique would you use to best detect an arterial aneurysm? A. Palpating for dilation of an artery B. Auscultating for a bruit over an artery C. Percussing for a thrill over an artery D. Observing for redness and swelling over an artery

B. Auscultating for a bruit over an artery Arterial anerysm is a localized dilation, generally defined as 1.5 times the diameter of the normal artery, caused by a weakness in the arterial wall. To best detect this anomaly, the examiner auscultates over an artery for a bruit.

Which of the following techniques is incorrect and affects the accuracy of auscultation? A. Placing the stethoscope firmly on the surface to be auscultated B. Auscultating through clothing C. Isolating one sound at a time during auscultation D. Listening for sound characteristics

B. Auscultating through clothing Auscultation involves listening for sounds produced by the body. Some sounds, such as speech, are audible to the unassisted ear. Place the stethoscope on the naked skin, because clothing obscures the sound. Listen not only for the presence of sound but also its characteristics: intensity, pitch, duration, and quality.

How do you obtain a blood pressure on a patient with a sustained cardiac dysrhythmia? A. Use palpation rather than auscultation. B. Average several blood pressure readings. C. Take the blood pressure on both arms and record the higher of the two. D. Use a sphygmomanometer with a Doppler device.

B. Average several blood pressure readings. If heart rate irregularity is sustained, take the average of several blood pressure readings and document the problem. Despite impeccable technique, cardiac dyshythmia is an example of a condition that may undermine the accuracy of blood pressure readings.

Mrs. Dublin is a 45-year-old patient who is referred to you with a lesion of the optic nerve at the optic chiasm. Which visual field defects would result from this lesion? A. Homonymous hemianopia B. Bitemporal hemianopia C. Binasal hemianopia D. Unilateral blindness

B. Bitemporal hemianopia Bitemporal hemianopia is caused by a lesion—most commonly a pituitary tumor—interrupting the optic chiasm.

Mrs. Nieland brings her toddler in for a routine office visit. She tells you that she has a new babysitter. Which finding is consistent with a physical abuse injury in a toddler? A. A burn to the skin with a splash pattern B. Bruising of the skin over soft tissue C. Bruising of the skin over a bony prominence D. Café au lait patches

B. Bruising of the skin over soft tissue Physical findings in children who are physically abused include bruises, burns, lacerations, scars, bony deformities, alopecia, retinal hemorrhages, dental trauma, and head and abdominal injuries. Bruising associated with abuse occurs over soft tissue; toddlers and older children who bruise themselves accidentally do so over bony prominences.

Which tool would you use to assess if a 5-month-old baby is in pain after abdominal surgery? A. Oucher pain scale. B. CRIES Scale C. FACES Scale D. Neonatal Infant Pain Scale

B. CRIES Scale The CRIES scale (Crying, Requires oxygen to keep saturation above 95, Increased vital signs, Expression, and Sleeplessness) is designed to evaluate postoperative pain in newborns and infants. The infant's behaviors (crying, expression, and sleeplessness) as well as physiologic signs (oxygen saturation, heart rate, and blood pressure) are scored (Witt et al., 2016).The Oucher Scale and the FACES Scale are used on children, not infants. The Neonatal Infant Pain Scale is used to assess procedure pain in preterm and full-term infants up to 6 weeks of age.

Antibodies induced by attack invaders create which of the following type of immunity? A. Humoral immunity B. Cellular immunity C. Immunocompetent immunity D. Effector immunity

B. Cellular immunity There are two types of immunity: (1) humoral, involving the antibodies produced by B cells; and (2) cellular, involving attacks on "invaders" by the cells themselves.

Mr. Tucker is a 68-year-old man who comes to your office complaining of spots on his skin. On examination, which lesion is an expected finding on the skin of healthy older adults? A. Acne vulgaris B. Cherry angioma C. Miliaria D. Trichotillomania

B. Cherry angioma Cherry angiomas are tiny, bright ruby-red, round papules that may become brown with time. They occur in virtually everyone older than 30 years and increase numerically with age.

Mrs. Black is a 35-year-old pregnant patient who presents to your office for follow-up. She complains of a brown patch of hyperpigmentation on her face. What is this condition found in pregnancy? A. Linea gravida B. Chloasma C. Carotenemia D. Café au lait spots

B. Chloasma Chloasma, or "mask of pregnancy," commonly occurs in pregnant women and is found on the forehead, cheeks, bridge of the nose, and chin. It is blotchy in appearance and is usually symmetric.

A generalized red coloration of the skin that occurs in inflammation or infection is described best by which of the following terms? A. Erythroid B. Erythema C. Cythemic D. Ecchymotic

B. Erythema Erythema is used to describe red or dark pink coloration of the skin.

Mr. Lynch has cyanotic lips and nailbeds. His lips are pursed, and he has nasal flaring. You suspect that he is suffering from cardiac or pulmonary difficulty. What other peripheral sign would support your impression? A. Callus formation on the heels B. Clubbing of the fingers C. Graying of the hair D. Swollen toes and ankles

B. Clubbing of the fingers Observe the lips and nails for cyanosis, the lips for pursing, the fingers for clubbing, and the alae nasi for flaring. Any of these peripheral clues suggests pulmonary or cardiac difficulty. Clubbing, enlargement of the terminal phalanges of the fingers and/or toes, is associated with emphysema, lung cancer, the cyanosis of congenital heart disease, or cystic fibrosis.

Nancy is a 14-year-old girl who presents at the clinic with complaints of severe, acute chest pain. Her mother reports that Nancy, apart from occasional colds, is not prone to respiratory problems. What factor is most important to assess relative to Nancy's present problem? A. Anorexia symptoms B. Cocaine use C. Last menses D. Signs of rheumatic fever

B. Cocaine use If an adult—especially a young adult—or an adolescent complains of severe, acute chest pain, ask about drug use, particularly cocaine. Cocaine can cause tachycardia, hypertension, coronary arterial spasm (with infarction), and pneumothorax (lung collapse) with severe, acute chest pain being the common result.

Which is the most rapid and critical period of brain growth? A. Birth to 1 year of age B. Conception to 3 years of age C. Birth to 4 years of age D. One to 2 years of age

B. Conception to 3 years of age The brain, along with the skull, eyes, and ears, completes physical development more quickly than any other body part. The most rapid and critical period of brain growth occurs between conception and 3 years of age.

Which finding is considered unusual in a newborn? A. Sneezing B. Coughing C. Prominence of the xiphoid process D. Nose breathing

B. Coughing Coughing is rare in the newborn and should be considered a problem. Sneezing, on the other hand, is frequent and expected—it clears the nose. Coughing in a newborn is considered unusual as it or difficulty breathing of sudden onset may indicate possible aspiration of small object, toy, or food.

What is the cause of barrel chest, which is characteristic of many older adults? A. Increased expansion of alveoli B. Decreased muscle strength and loss of lung resiliency C. Decreased expansion of alveoli and increased lung resiliency D. Increased blood pressure and decreased amount of body fat

B. Decreased muscle strength and loss of lung resiliency The barrel chest that is seen in many older adults results from loss of muscle strength in the thorax and diaphragm, coupled with the loss of lung resiliency. In addition, skeletal changes of aging tend to emphasize the dorsal curve of the thoracic spine, resulting in an increased anteroposterior (AP) chest diameter.

Which of the following conditions, if present, will alter the skin turgor of an individual? A. Jaundice B. Dehydration C. Vitiligo D. Cyanosis

B. Dehydration The skin should move easily when pinched and return to place immediately when released. Poor skin turgor can indicate severe dehydration. The skin is very slow to return to normal and "tents" up. This may occur with excessive vomiting, diarrhea, or dehydration for another cause.

In which of the following situations is transillumination an appropriate examination technique? A. Assessment of vesicles on the skin B. Detection of fluid within the sinuses C. Measurement of bone density in the skull D. Determination of a mass in the abdomen

B. Detection of fluid within the sinuses A transilluminator consists of a strong light source with a narrow beam. The beam is directed to a particular body cavity and is used to differentiate between various media present in that cavity. Air, fluid, and tissue differentially transmit light; this allows you to detect the presence of fluid in sinuses or the presence of blood or masses in the scrotum.

Which of the following information is particular to a pediatric history? A. Family history B. Developmental history C. Social history D. Past medical history

B. Developmental history The developmental history tells the examiner when the child achieved developmental milestones and is a key indicator in discerning developmental delays.

Which factor increases the susceptibility of older adults to respiratory infection? A. Less elastic alveoli B. Drier mucous membranes C. Decreased tensile strength of the respiratory muscles D. Increased exposure to air pollution

B. Drier mucous membranes Aging mucous membranes tend to become drier, and older adults are less able to clear mucus. Retained mucus encourages bacterial growth and predisposes the older adult to respiratory infection.

Mr. Telford tells you that he feels short of breath and has difficulty breathing after climbing the stairs in his home. Based on his description, what term might be used to identify his breathing condition? A. Orthopnea B. Dyspnea C. Kussmaul D. Hyperpnea

B. Dyspnea Dyspnea is difficult and labored breathing with shortness of breath, commonly observed with pulmonary or cardiac compromise.

Which is a determinant of the degree of retraction on inspiration? A. Respiratory rate B. Extent of obstruction C. Body temperature D. Angle of the head of the bed

B. Extent of obstruction As intrapleural pressure becomes increasingly negative, the musculature "pulls back" in an effort to overcome blockage. Any significant obstruction makes the retraction observable with each inspiratory effort. The degree and level of retraction depend on the extent and level of obstruction (see Box 14.6).

You note asymmetry affecting the lower right side of a patient's face. You would suspect a problem with which nerve? A. Trigeminal B. Facial C. Hypoglossal D. Trochlear

B. Facial Suspect facial nerve paralysis when the entire side of the face is affected, and suspect facial nerve weakness when the lower face is affected.

Direct, objective, and logical are typical characteristics of verbal communication among the Japanese and other Asian people. A. True B. False

B. False In the United States, people are direct in conversation and are eager to be thought logical, preferring to avoid the subjective and to come to the point quickly. The Japanese tend to do the opposite, using indirection, talking around points, and emphasizing attitudes and feelings.

The verbal and nonverbal expression of emotions is not related to culture. A. True B. False

B. False Communication and culture are interrelated, particularly in the way feelings are expressed verbally and nonverbally. The same word may have different meanings for different people.

Language is not considered a part of culture. A. True B. False

B. False Culture, in its broadest sense, reflects the whole of human behavior, including ideas and attitudes; ways of relating to one another; manners of speaking; and the material products of physical effort, ingenuity, and imagination. Language is a part of the culture. So, too, are the abstract systems of belief, etiquette, law, morals, entertainment, and education. Within the cultural whole, different populations may exist in groups and subgroups.

A patient has a urinary tract infection. The examiner wishes to assess tenderness over the kidney. Which examination technique is appropriate? A. Light finger palpation over the kidney B. Firm fist percussion over the kidney C. Deep abdominal palpation of the kidney D. Auscultation for kidney bruit

B. Firm fist percussion over the kidney Fist percussion is most commonly used to elicit tenderness arising from the liver, gallbladder, or kidneys. In this technique, use the ulnar aspect of the fist to deliver a firm blow to the area.

A father brings his 3-year-old daughter to your office because she has been wheezing for the past 12 hours. The child has no history of health problems and has had regular well child visits. On examination, you find that the wheeze is asymmetric. What problem do you suspect? A. Allergic reaction B. Foreign body in the respiratory tract C. Onset of environmentally induced asthma D. Atypical croup

B. Foreign body in the respiratory tract Unilateral or more sharply localized wheezing or stridor may occur with a foreign body.

Which fact reported in a patient's history indicates increased risk for a pterygium? A. Recent episode of carotinemia B. Frequent sunbathing C. Ingestion of megadoses of vitamin C D. History of skin tags

B. Frequent sunbathing A pterygium is an abnormal growth of conjunctiva that extends over the cornea from the limbus. It occurs more commonly on the nasal side but may arise temporally as well. A pterygium is more common in people heavily exposed to ultraviolet light.

Which piece of equipment is most essential for proper examination of the thyroid? A. Tape measure B. Glass of water C. Flashlight D. Skin pencil

B. Glass of water A glass of water is an indispensable aid for proper examination of the thyroid; it helps the patient swallow multiple times. Palpation of the thyroid gland requires a gentle touch.

Until the age of 2 years, this part of an infant/toddler's body is measured at each visit. A. Shoe size B. Head circumference C. Length D. Weight

B. Head circumference The infant's head circumference is measured at every health visit until 2 to 3 years of age. Compare measurements over time to monitor the head circumference growth pattern. This allows the examiner to assess the growth pattern for deviations from the expected norm.

Wheezes are produced by which of the following? A. Fluid-filled airways opening up during inspiration B. High-velocity air flow through a narrowed airway C. Collapse of the airways during expiration D. Shunting of air away from an area of consolidation

B. High-velocity air flow through a narrowed airway A wheeze (sibilant wheeze) is sometimes thought of as a form of rhonchus. It is a continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration. It is caused by a relatively high-velocity air flow through a narrowed or obstructed airway.

Which would be the correct way to document your findings related to assessment of an intravenous (IV) line insertion site? A. IV site appears normal. B. IV site free of redness, tenderness, and swelling. C. IV site looks good. D. IV site negative for adverse signs of functionality.

B. IV site free of redness, tenderness, and swelling. Assessment includes anticipated potential problems, if appropriate (e.g., complications, progression of disease, sequelae).

Which is an appropriate action related to parts of the examination that were omitted? A. Record the data as negative information. B. Identify those parts that were omitted. C. Say nothing about the part that was not included. D. Record the information and draw a line through it indicating omission.

B. Identify those parts that were omitted. Any portion of the examination that has been deferred or omitted should be so noted, rather than neglecting to mention particular findings.

Which is often the cause of a pericardial friction rub? A. Inflammation of the AV and semilunar valves B. Inflammation of the pericardium C. Holosystolic murmur D. Protodiastolic gallop

B. Inflammation of the pericardium A pericardial friction rub can be easily mistaken for cardiac-generated sounds. Inflammation of the pericardial sac causes a roughening of the parietal and visceral surfaces, which produces a rubbing machine-like sound audible on auscultation. It occupies both systole and diastole and overlies the intracardiac sounds.

Which of the following structures dilates or contracts to allow light into the eye? A. Pupil B. Iris C. Lens D. Rectus muscle

B. Iris The iris is a circular, contractile muscular disk containing pigment cells that produce the color of the eye. The central aperture of the iris is the pupil, through which light travels to the retina. By dilating and contracting, the iris controls the amount of light reaching the retina.

A mother tells the examiner that her 2-year-old child has a cough that "sounds just like a bark." Given this history, which other findings should the examiner anticipate with respiratory examination? A. Wheezing and coarse crackles bilaterally B. Labored breathing and inspiratory stridor C. Hyperresonance with percussion D. Productive, blood-tinged, or "rusty" sputum

B. Labored breathing and inspiratory stridor Croup or laryngotracheal bronchitis is a syndrome that generally results from infection with a variety of viral agents, particularly the parainfluenza viruses occurring most often in children from about 1½ to 3 years of age. Objective data include labored breathing, retraction, hoarseness, barking cough, and inspiratory stridor.

You are completing a fundoscopic examination on a 45-year-old patient. During the examination, you note a red light reflex. What does this indicate? A. Normal hemoglobin content of the retina B. Light illuminating the retina C. Adequate dilation of the pupil D. Retinal hemorrhage

B. Light illuminating the retina The red reflex is caused by the light illuminating the retina. Any opacities in the path of the light will stand out as black densities. Absence of the red reflex is often the result of an improperly positioned ophthalmoscope, but it may also indicate total opacity of the pupil by a cataract or by hemorrhage into the vitreous humor.

For which part of a physical examination might the left side down lateral recumbent position appropriately be used? A. Palpating the liver B. Listening to heart sounds C. Inspecting the perineum D. Percussing the thorax

B. Listening to heart sounds The left lateral recumbent position is a side-lying position, with legs extended or flexed. This position in which the patient's left side is down may be used in listening to heart sounds or palpating the spleen.

Which group is associated with the highest morbidity and mortality rates in the United States? A. Middle class women B. Low economic groups C. White collar professionals D. Upper class men

B. Low economic groups Poverty and inadequate education disproportionately affect various cultural groups (e.g., ethnic minorities and women); socioeconomic disparities negatively affect the health and medical care of individuals belonging to these groups.

Which chest structure contains all the thoracic viscera except the lungs? A. Manubrium B. Mediastinum C. Sternum D. Xiphoid

B. Mediastinum The interior of the chest is divided into three major spaces: the right and left pleural cavities and the mediastinum. The mediastinum, situated between the lungs, contains the heart and major blood vessels. The pleural cavities are lined with serous membranes (parietal and visceral pleurae), which enclose the lungs.

Skin color is dependent on which of the following cells? A. Carotenocytes B. Melanocytes C. Dermatocytes D. Keratinocytes

B. Melanocytes Melanocytes are the cells that synthesize melanin. Melanin gives the skin its color.

At what point during pregnancy would you expect the patient's blood pressure to be at its lowest point? A. End of the first trimester B. Mid-pregnancy C. Beginning of the third trimester D. Just before term

B. Mid-pregnancy During pregnancy, blood pressure commonly decreases beginning at about 8 weeks' gestation, gradually falling until a low point is reached at mid-pregnancy.

Ms. Jones is a 25-year-old patient who presents to your office with a complaint of severe pulsating headaches accompanied by nausea, vomiting, and scotoma. Which type of headache would you conclude that Ms. Jones has? A. Temporal B. Migraine C. Cluster D. Traumatic

B. Migraine Migrane is a type of headache (pain in the head) that presents as pulsating or throbbing, accompanied by nausea, vomiting, and scotoma.

An examiner is most likely to observe pseudostrabismus in which of the following groups? A. Older or frail adults B. Native American/American Indian infants C. Pregnant women D. Hispanic schoolchildren

B. Native American/American Indian infants Pseudostrabismus, the false appearance of strabismus caused by a flattened nasal bridge or epicanthal folds, is an expected variant in Asian and Native American/American Indian infants, as well as in some whites.

Mr. Adams is a 57-year-old man who presents to your office with a complaint of burning and shocklike pain in his left forearm. What type of damage does this indicate? A. Bone and soft tissue damage B. Nerve tissue damage C. Vascular damage D. Tissue inflammation

B. Nerve tissue damage Burning, shocklike pain is most indicative or nerve tissue damage.

Fibers that originate on the nasal retina decussate (cross over) at what point in the optic pathway? A. Optic tract B. Optic chiasm C. Optic radiation D. Optic cortex

B. Optic chiasm Accurate binocular vision is achieved when an image is fused on the retina by the cornea and the lens. An object may be perceived in each visual cortex, even when one eye is covered, if the light impulse is cast on both the temporal and the nasal retina. Fibers located on the nasal retina decussate in the optic chiasm.

Which disease manifests as a heavy, throbbing, aching pain? A. Carpal tunnel syndrome B. Ovarian tumor pressing on bowel C. Headache after seizure D. Chest pain

B. Ovarian tumor pressing on the bowel Heavy, throbbing, and aching pain is the classic pain pattern associated with a tumor pressing on a cavity. An ovarian tumor pressing on a bowel is an example of this situation.

Mr. Jones is a 47-year-old construction worker who presents to your office with a complaint of knee pain. Which is the correct way to record an individual's severity of pain perception? A. "My knee hurts." B. Pain in knee rated as 6 on 1 to 10 scale. C. "My knee hurts today, a lot more than it did yesterday." D. Knee appears swollen and red; warm to touch.

B. Pain in knee rated as 6 on 1 to 10 scale. Record the severity of pain using the patient's response or score on a pain scale. Be sure to name the pain scale in the record. The severity of pain may also be described by its interference with activity or disruption of sleep. A clear, exact record of your assessment, an analysis of the problem, and a management plan are vital for communicating with consultants and for your protection in case there is ever a question relevant to your care of the patient.

Which of the following statements is true regarding palpation? A. Palpation should only be used when necessary because it involves the individual's personal space. B. Palpation may be symbolically interpreted as the "laying on of hands." C. Palpation is only used to validate data obtained via the other three techniques. D. Palpation technique does not matter because, regardless of how you do it, the individual will feel better because of it.

B. Palpation may be symbolically interpreted as the "laying on of hands." Palpation involves the use of the hands and fingers to gather information through the sense of touch. Touch is in many ways therapeutic, and palpation is the actuality of the "laying on of hands."

What information is provided through use of a pain scale? A. Patient's emotional response of pain B. Patient's intensity of pain C. Patient's quality of pain D. Patient's expected pain intensity

B. Patient's intensity of pain A pain scale is used to rate the intensity of pain and the effectiveness of pain management interventions.

Which of the following instruments is used in conjunction with a simple nasal speculum to visualize the lower and middle turbinates of the nose? A. Otoscope B. Penlight C. Ophthalmoscope D. Goniometer

B. Penlight Use the nasal speculum with a penlight to visualize the lower and middle turbinates of the nose. Be sure that the patient is in a comfortable position. You may need to support the patient's head, or you can have the patient lie down.

What is the major function of the heart valves? A. Separate the right side of the heart from the left B. Permit the flow of blood in one direction C. Separate the upper chambers from the lower chambers D. Augment the flow of blood through the heart

B. Permit the flow of blood in one direction The four chambers of the heart are connected by two sets of valves: the atrioventricular and semilunar valves. In the fully formed heart that is free of defect, these are the only intracardiac pathways and permit the flow of blood in only one direction.

Clubbing of the fingernail is commonly associated with: A. anemia. B. respiratory disorders. C. cancer. D. trauma.

B. respiratory disorders. Clubbing of the fingernail is associated with a variety of respiratory and cardiovascular diseases, cirrhosis, colitis, and thyroid disease.

Mr. French is a 67-year-old patient who presents to your office with the following complaint: "I have a loss of vision in the outer half of each eye." Which of the following underlying problems should the examiner consider? A. Diabetes B. Pituitary tumor C. Glaucoma D. Cytomegalovirus (CMV) infection

B. Pituitary tumor Bitemporal hemianopia is caused by a lesion—most commonly a pituitary tumor—interrupting the optic chiasm.

You are assessing a patient and find that that the dorsalis pedis pulse is not palpable. Which pulse would you palpate next for maximum information about the blood flow to the distal extremity? A. Femoral B. Posterior tibial C. Popliteal D. Carotid

B. Posterior tibial The pulses are best palpated over arteries that are close to the surface of the body and lie over bones. These include the carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. An arterial pulsation is essentially a bounding wave of blood that diminishes with increasing distance from the heart. The carotid pulses are most easily accessible and closest to the cardiac source, making them most useful in evaluating heart function. Examine the arterial pulses in the extremities to determine the sufficiency of the entire arterial circulation. Palpate at least one pulse point in each extremity, usually at the most distal point.

Which of the following problems manifests as a burning pain? A. Irritable bowel syndrome B. Radiculopathy C. Headache D. Fractured tibia

B. Radiculopathy Patients with radiculitis, also known as radiculopathy, may experience burning, intense tightness, shooting, stabbing, or shocklike sensations. Radiculopathy is a potential cause of chronic neuropathic pain.

You are responding to a patient who has behaved toward you in a seductive manner. Which of the following is most appropriate? A. Respond in a manner that acknowledges that the patient is embarrassed. B. Remain calm, firm, and direct regarding the professional nature of the relationship. C. Be courteous. D. Ignore the patient's behavior.

B. Remain calm, firm, and direct regarding the professional nature of the relationship. This type of patient is seeking additional attention. Avert it courteously and firmly, delivering the immediate message that the relationship is and will remain professional. It takes skill to do this while maintaining the patient's dignity, but there is no room for sexual misconduct in the relationship, and there can be no tolerance for exploitation of the patient in this regard.

Which statement best describes the chief complaint? A. General health and illness B. The reason the individual is seeking care C. Information to make the diagnosis D. Concerns about confidentiality and trust

B. The reason the individual is seeking care The chief complaint is the main reason the person is seeking care or the chief concern. The other answers are parts of the history and physical or review of symptoms.

Mrs. Hammond is a 55-year-old woman who comes to the office for her yearly physical examination. Mrs. Hammond wears glasses for astigmatism and farsightedness. Which of the following statements regarding her eye examination technique is true? A. Use the green color dial because of the astigmatism. B. Rotate the lens selector dial to the black numbers to compensate for her farsightedness. C. Rotate the lens selector dial to the red numbers to compensate for her farsightedness positive magnification. D. Rotate the lens selector dial to the black numbers to compensate for her astigmatism.

B. Rotate the lens selector dial to the black numbers to compensate for her farsightedness. The system of plus and minus lenses can compensate for myopia or hyperopia in both the examiner and the patient. There is no compensation for astigmatism.

A patient presents with multiple raised lesions on her skin. What instrument can help examine these lesions? A. Calipers B. Ruler C. Tympanometer D. Transilluminator

B. Ruler The ruler, which can be used to measure skin lesions, is among other devices you should personally own because it will be used the most often.

A 26-year-old woman presenting for a preemployment physical is found to have bruising on her back and buttocks. What would be your best immediate response? A. Ask, "Would you care to tell me about these bruises on your back and buttocks?" B. Say, "I see bruises. How did you get them?" C. Ask, "Do you feel safe in your current relationships?" D. Say, "I am required by the law to document these bruises, so I am asking your permission to take a picture of them."

B. Say, "I see bruises. How did you get them?" Should the examiner see something suggestive like bruises, follow-up questions are required. "How did you get them" is an appropriate nonjudgmental follow-up question. Answers a, c, and d are representative of judgmental questions.

Where would you place your stethescope to auscultate the pulmonic valve area? A. Fourth left intercostal space along the lower left sternal border B. Second left intercostal space at the left sternal border C. Second right intercostal space at the right sternal border D. Third left intercostal space at the left sternal border

B. Second left intercostal space at the left sternal border The pulmonic valve separates the right ventricle from the pulmonary artery. To auscultate the pulmonic valve, the examiner places the stethoscope at the second left intercostal space at the left sternal border.

How does the APSO patient record format differ from the SOAP format? A. Categories of information B. Sequence of information C. Amount of detail D. Level of specificity

B. Sequence of information The problem-oriented medical record (POMR) with SOAP (Subjective, Objective, Assessment, and Plan) notes is one system for organizing documentation. The POMR can also be created in the APSO (Assessment, Plan, Subjective, and Objective) format.

Caput succedaneum, a form of birth trauma, is characterized by which of the following? A. A collection of blood in the subperiosteum B. Subcutaneous edema over the presenting part of the head C. Enlargement of the fontanels caused by fluid leaking into the periosteal spaces D. Bulging of the skull in the frontal area as a result of premature birth

B. Subcutaneous edema over the presenting part of the head Caput succedaneum is subcutaneous edema over the presenting part of the head at delivery. It is the most common form of birth trauma of the scalp and usually occurs over the occiput and crosses suture lines. The affected part of the scalp feels soft, and the margins are poorly defined. Generally, the edema goes away in a few days.

Mr. Santos is a 45-year-old man with a complaint of headache. Which type of assessment is the best indicator of his pain? A. Computed tomography scan of the head B. Subjective report C. Neurologic examination findings D. Alterations in vital signs

B. Subjective report Pain is a subjective unpleasant symptom of many conditions and injuries. The pain experience and its characteristics and intensity are unique for each person. The other choices are examples of objective data.

Infection in which anatomic area can cause inguinal lymph node enlargement? A. Testes B. Surface of the penis C. Prostatic capsule D. Lower uterine segment

B. Surface of the penis The lymphatic drainage of the testes is into the abdomen. Enlarged nodes there are not accessible to inspection and palpation. Nodes in the inguinal area enlarge if there are lesions of the penile and scrotal surfaces.

Which of the following is a type of blood cell that has a life span of 100 to 200 days? A. B cells B. T cells C. Stem cells D. Marrow-derived cells

B. T cells T cells, which are four or five times as numerous as B cells, have a life span of 100 to 200 days. B cells live 3 to 4 days.

Mr. Garges is a 64-year-old patient who is experiencing calf pain when he exercises. Pain that results from muscle ischemia is identified as: A. ischemia muscularis. B. claudication. C. obstructive. D. Raynaud syndrome.

B. claudication. Claudication is pain caused by compromised blood flow to muscles resulting in muscular ischemia. It usually occurs during exercise and is a symptom of peripheral artery disease in which the vessels that supply blood flow to your legs or arms are narrowed.

To best hear a splitting of the S2 sound unaffected by the respiratory cycle, which direction would you give the patient? A. Take a series of rapid, shallow breaths, then exhale deeply. B. Take a deep breath and hold it. C. Lie on your left side with your neck down and knees bent. D. Breathe quietly through your mouth.

B. Take a deep breath and hold it. S2, the result of closure of the aortic and pulmonic (semilunar) valves, indicates the end of systole and is best heard in the aortic and pulmonic areas. It is of higher pitch and shorter duration than S1. Splitting of S2 is an expected event, because pressures are higher and depolarization occurs earlier on the left side of the heart. During inspiration, the lungs fill with air as the chest wall expands. Ejection times tend to equalize when the breath is held in expiration, so this maneuver also tends to eliminate the split. The respiratory cycle is not always the dominant factor in splitting; the interval between the components may remain easily discernible throughout the respiratory cycle.

Mrs. Amons is a 52-year-old patient who presents to your office with a complaint of fever, malaise, muscle aches, mild loss of vision, and a severe throbbing headache. On examination, you note a red, swollen temporal artery. Which of the following best describes these clinical signs and symptoms? A. Arterial aneurysm B. Temporal arteritis C. Arterial thrombosis D. Venous thrombosis

B. Temporal arteritis Temporal arteritis, or giant cell arteritis, is an inflammatory disease of the branches of the aortic arch, including the temporal arteries. Mrs. Amons is displaying classic symptoms of this conditions.

The thick muscular middle layer of the heart that is responsible for contraction is the: A. atrial musculorum. B. myocardium. C. chordae tendineae. D. ventricular muscularis.

B. The myocardium, the thick muscular middle layer, is responsible for the pumping action of the heart.

Pain has been referred to as the fifth vital sign. Which statement is true of pain and its management? A. Pain is exclusively a physiologic response. B. The patient determines what is an unacceptable pain level. C. Tolerance and addiction to pain medication are universal phenomena. D. There is a single cause of pain for each patient.

B. The patient determines what is an unacceptable pain level. The patient's experience of pain is a subjective phenomenon. The patient's report of pain is the most reliable indicator of pain, and therefore the other choices do not apply.

A 22-year-old college student presents for a routine physical examination. Which finding would you expect on examination of the student's thyroid gland? A. The gland decreases when the student swallows. B. The right lobe is about a quarter larger than the left. C. A soft rushing sound is heard on auscultation of the gland. D. The glandular tissue feels gritty but free of nodules.

B. The right lobe is about a quarter larger than the left. The thyroid at its broadest dimension is approximately 4 cm, and the right lobe is often 25% larger than the left.

Mr. Sanchez is a 62-year-old patient who presents with chronic obstructive lung disease. Which finding on examination leads you to document that Mr. Sanchez has a barrel chest? A. There is a decrease in the anteroposterior diameter of the chest. B. There is an increase in the anteroposterior diameter of the chest. C. There is a decrease in the transverse diameter of the chest. D. There is an increase in the transverse diameter of the chest.

B. There is an increase in the anteroposterior diameter of the chest. Increased anteroposterior diameter of the chest or barrel chest is a classic symptom of chronic conditions like chronic obstructive pulmonary disease (COPD).

Mr. Sherman is a 65-year-old patient who has long-standing hypertension. Which clinical finding would you expect? A. Decreased blood volume B. Thickened myocardium C. Increased stroke volume D. Decreased cardiac irritability

B. Thickened myocardium Heart size may decrease with age unless hypertension or heart disease causes enlargement. The myocardium becomes less elastic and more rigid so that recovery of myocardial contractility is delayed.

Mr. Green is a 63-year-old patient who is having a driver's physical examination completed. On examination, you note a senile hyaline plaque. Which of the following best describes this finding? A. This is a normal finding depending on the amount of melanin in the pigment epithelium. B. This is a dark, slate gray pigment just anterior to the insertion of the medial rectus muscle. C. This is a small, discrete spot slightly more yellow than the retina. D. This is a slightly raised, irregularly shaped yellow tinted lesion.

B. This is a dark, slate gray pigment just anterior to the insertion of the medial rectus muscle. Senile hyaline plaque appears as a dark, slate gray pigment just anterior to the insertion of the medial rectus muscle. Its presence does not imply disease but should be noted.

The health professional has a responsibility to use a "gender-affirming" approach when performing a physical examination on which patients? A. Preschool children B. Transgender individuals C. Women who have undergone hysterectomy D. Infertility patients

B. Transgender individuals It is imperative that health care providers invest time in becoming culturally competent and develop cultural humility to work effectively with lesbian, gay, bisexual, and transgender (LGBT) patients. Specific responsibilities include providing a welcoming and safe environment, gathering a history with sensitivity and compassion, and performing a physical examination using a "gender-affirming" approach (i.e., using the correct name and pronouns).

1. Mrs. Jones has brought her 4-month-old female infant in for her routine physical. Which statement is true about the baby's expected weight? A. Weight doubles during the first 3 months, then triples by 1 year. B. Weight doubles during the first 4 to 5 months, then triples by 1 year. C. Weight doubles during the first 6 months, and doubles again by 1 year. D. Weight doubles during the first 6 months, and then triples by 18 months.

B. Weight doubles during the first 4 to 5 months, then triples by 1 year. In general, infants double their birth weight by 4 to 5 months of age and triple their birth weight by 12 months of age. The remaining answers are not true.

S3 and S4 are commonly heard in which of the following groups of individuals? A. Older adults B. Young children C. Middle-aged adults D. Pregnant women

B. Young children S3 and S4 are commonly heard in pediatric patients. Increased intensity of either sound is suspect.

Crepitus is caused by: A. inflammation of the pleural lining. B. air in the subcutaneous spaces. C. a foreign body located in the right mainstem bronchus. D. a convergence of alveoli causing multiple bleb formations.

B. air in the subcutaneous spaces. Crepitus, a crackly or crinkly sensation, can be both palpated and heard—a gentle, bubbly feeling. It indicates air in the subcutaneous tissue from a rupture somewhere in the respiratory system or by infection with a gas-producing organism.

Ms. Williams is a 21-year-old patient who presents to your office. On examination, you find a cobblestone appearance of the conjunctiva. This is most likely related to: A. subconjunctival hemorrhage. B. allergic or infectious conjunctivitis. C. lagophthalmos. D. cytomegalovirus infection.

B. allergic or infectious conjunctivitis. An erythematous or cobblestone appearance, especially on the tarsal conjunctiva, may indicate an allergic or infectious conjunctivitis.

Mr. Scottman is a 55-year-old patient who complains of a bilateral watery discharge from the nose that is associated with sneezing and nasal congestion. This is indicative of a(n): A. upper respiratory infection. B. allergy. C. fracture of the cribriform plate. D. presence of a foreign body in the nasal passage.

B. allergy. Allergeries are one potential condition associated with nasal discharge, which includes bilateral watery discharge, associated sneezing, and nasal congestion.

During an interview, the patient describes problems associated with an illness and begins to cry. The best action in this situation is to: A. stop the interview and reschedule for another time. B. allow the patient to cry, then resume when the patient is ready. C. change the topic to something less upsetting. D. continue the interview while the patient cries in order to get through it quickly.

B. allow the patient to cry, then resume when the patient is ready. People will cry. Let the emotion proceed at the patient's pace. Resume your questioning only when the patient is ready. If you suspect a patient is holding back, give permission. Offer a tissue or simply say, "It seems like you're feeling bad. It's okay to cry." Name the emotion. Be direct about such a tender circumstance, but gently, not too aggressively or insistently.

Stroke volume is defined as the: A. amount of blood ejected per minute. B. amount of blood ejected per heartbeat. C. amount of blood ejected per second. D. combined amount of blood contained within each atria.

B. amount of blood ejected per heartbeat. Oxygenated blood of the systemic circulation returns to the heart and enters the systemic circulation through the pulmonary veins into the left atrium, then through the mitral valve into the left ventricle. The left ventricle contracts, forcing a volume of blood with each beat (stroke volume) through the aortic valve into the aorta, where it is distributed systemically through the arteries and capillaries.

Skin color in a newborn is partly determined by: A. gestational age. B. amount of fat. C. composition of the vernix caseosa. D. amount of lanugo present.

B. amount of fat. In the first few hours of life, the infant's skin may look very red. The gentle pink coloring that predominates in infancy usually surfaces in the first day after birth. Skin color is partly determined by the amount of subcutaneous fat: The less subcutaneous fat, the redder and more transparent the skin.

The tongue is anchored to the floor of the mouth by the: A. mandibular tendinea. B. frenulum. C. gums. D. sublingual ligaments.

B. frenulum. Loose, mobile tissue covering the mandibular bone forms the floor of the mouth. The tongue is anchored to the back of the oral cavity at its base and to the floor of the mouth by the frenulum.

Mr. Marlin is a 58-year-old man who presents to your office for a follow-up examination. You are treating him for rosacea. Rosacea is: A. a recurrent disease of keratin synthesis. B. an inflammatory skin disorder with papules and pustules. C. an area filled with fluid near the skin of the nose. D. macules connected to the dermis by keratinocytes.

B. an inflammatory skin disorder with papules and pustules. Rosacea is a chronic inflammatory disorder characterized by telangiectasia, erythema, papules, and pustules that occur particularly in the central area of the face. Although it resembles acne, comedones are never present.

When questioning a patient regarding a sensitive issue such as drug use, it is best to: A. begin by describing the effects of drug abuse on health. B. be direct, firm, and to the point. C. explain that only health care workers will share the information. D. explain that only health care workers will share the information.

B. be direct, firm, and to the point. Sensitive issues, which may be difficult to discuss but are important to address, include sex, drug or alcohol use, or concerns about death. Being direct, firm, and to the point are successful techniques used in these types of interviews. Answers a, c, and d, have proven to be ineffective techniques in these situations.

Mr. Jones presents to your office following a fistfight. On examination of the tympanic membrane, you notice a blue color. This indicates the patient has: A. a cerebral spinal fluid leak. B. blood in the middle ear. C. high wax production. D. fluid in the middle ear.

B. blood in the middle ear. A blue or deep red color noted in the tympanic membrane indicates blood in the middle ear.

Mr. Green is a 37-year-old patient who presents to your office with a complaint of upper arm pain that is tender, deep, and aching. This type of pain usually indicates: A. tissue inflammation. B. bone and soft tissue pain. C. nerve pain. D. vascular damage.

B. bone and soft tissue pain. Tender, deep, and aching are classic descriptors of pain related to bone and soft tissue damage.

Breath sounds are best heard if the patient: A. hyperventilates for 30 seconds before auscultation. B. breathes slowly and deeply through the mouth. C. breathes normally. D. inhales through the nose and exhales through the mouth.

B. breathes slowly and deeply through the mouth. To assess the patient's breath sounds, have the patient sit upright, if possible, and breathe slowly and deeply through the mouth, exaggerating normal respiration. This allows for full lung expansion.

Inspection differs from palpation, percussion, and auscultation in that it: A. is useful only to trained individuals. B. can be used continuously throughout the history and examination. C. is dependent on the other three processes. D. always requires validation via the other processes.

B. can be used continuously throughout the history and examination. Inspection is the process of observation. Your eyes and nose are sensitive tools for gathering data throughout the examination. Inspection—unlike palpation, percussion, and auscultation—can continue throughout the history-taking process and during the physical examination.

Mrs. Yates is a 55-year-old patient who presents to your office with complaints of chest pain. To relate precordial palpation findings to the timing of the cardiac cycle, you place one hand over the precordium and the other hand over the: A. jugular pulse. B. carotid pulse. C. brachial pulse. D. femoral pulse.

B. carotid pulse. While palpating the precordium, use your other hand to palpate the carotid artery so that you can describe the finding in relation to the cardiac cycle. The carotid pulse and S1 are practically synchronous. The carotid pulse is located just medial to and below the angle of the jaw.

Visual acuity is essentially a measurement of: A. lens accommodation. B. central vision. C. depth perception. D. cranial nerve II, III, and VI integrity.

B. central vision. Measurement of visual acuity—the discrimination of small visual details—tests CN II (optic nerve) and is essentially a measurement of central vision.

Before instilling a mydriatic eyedrop into a patient's eye for examination, the examiner should: A. assess the corneal reflex. B. check for a shallow anterior chamber. C. assess intraocular pressure. D. observe the eye for vascular changes.

B. check for a shallow anterior chamber. Before instillation of a mydriatic, inspect the patient's anterior chamber by shining a focused light tangentially at the limbus (the union of the conjunctiva and the sclera). Note the illumination of the iris nasally. This portion of the iris is not lighted when the patient has a shallow anterior chamber, indicating a risk of acute-angle glaucoma. Mydriatics should be avoided in these patients.

Mr. Fitzgerald is a 26-year-old patient who complains of chronic sniffling, nasal congestion, nosebleeds, mucosal scabs, and septum perforation. You would suspect: A. chronic allergies. B. cocaine abuse. C. fungal infection. D. turbinate hypertrophy.

B. cocaine abuse. When individuals nasally insufflate ("snort", "sniff") cocaine, signs of recent use include rhinorrhea, hyperemia, and edema of the nasal mucosa. White powder may still be present on the nasal hairs. Signs of chronic use include scabs on the nasal mucosa, decreased perception of taste and smell, and perforation of the nasal septum.

Use of the phrase "patient denies" in recording the nonexistence of symptoms has a negative connotation and may imply that the individual is: A. noncompliant. B. confrontational. C. deceptive. D. reactionary.

B. confrontational. The term denies may imply a confrontational or unproductive relationship.

Ptosis is a condition in which the eyelid: A. does not cover any portion of the iris. B. covers a portion of the iris and sometimes a portion of the pupil. C. is unable to cover any portion of the eyeball. D. is turned inward toward the globe.

B. covers a portion of the iris and sometimes a portion of the pupil. Ptosis indicates a congenital or acquired weakness of the levator muscle or a paresis of a branch of the third cranial nerve. Record the difference between the two lids in millimeters. It is a condition of the eyelid.

A habitual activity passed along by family members is a: A. ritual. B. custom. C. belief. D. norm.

B. custom. A custom is a traditional practice within a specific group.

Percussion tones are a reflection of the _____ of the medium through which the sound waves travel. A. mobility B. density C. temperature D. dissonance

B. density The density of the medium through which the sound waves travel determines the percussion tone. The more dense the medium, the quieter the percussion tone.

Acceleration of sweat and sebaceous gland activity during pregnancy is for the purpose of: A. increasing elimination of waste products from the fetus. B. dissipating excessive heat from increased metabolism. C. promoting peripheral vasodilation of the increased numbers of capillaries. D. facilitating fat deposition to create better insulation for heat conservation.

B. dissipating excessive heat from increased metabolism. Acceleration of sweat and sebaceous gland activity occurs. Both processes assist in dissipating the excess heat caused by increased metabolism during pregnancy.

Both pleural effusion and pneumonia are characterized by: A. tympany heard with percussion. B. dullness heard on percussion. C. resonance heard on percussion. D. hyperresonance heard on percussion.

B. dullness heard on percussion. Dullness or flatness suggests pneumonia, atelectasis, pleural effusion, pneumothorax, or asthma.

Because an adolescent is often reluctant to talk during an interview, it is best to: A. tell the patient that you must have straight answers to your questions. B. ensure confidentiality regarding the information discussed. C. inform the patient that adolescents have trouble expressing their feelings. D. obtain the history from a parent or other family member.

B. ensure confidentiality regarding the information discussed. Adolescents may be reluctant to talk and have a clear need for confidentiality. All adolescent patients should be given the opportunity to discuss their concerns with you privately. It is wise to let parents or other caregivers know you will be asking them to step out of the room to provide this important opportunity for the adolescent.

A mother runs into the emergency department with her 6-year-old son. She says that her son fell 15 feet from a tree. The child is screaming and has an open fracture of the left forearm. You would conduct a(n): A. complete history. B. focused history. C. problem-oriented history. D. interim history.

B. focused history. The focused history is taken when the problem is acute, possibly life threatening, and requiring immediate attention so that only the need of the moment is given full attention.

Your trauma patient has no auscultated breath sounds in the right lung field. You can hear adequate sounds in the left side. A likely cause of this abnormality could be that the patient: A. has a closed head injury. B. has fluid in the pleural space. C. is moaning in severe pain. D. is receiving high oxygen flow.

B. has fluid in the pleural space. Pleural effusion, which is an excess of nonpurulent fluid in the pleural space, is characterized by muted breath sounds in the affected area.

In addition to the head, neck, axilla, and inguinal areas, the examiner may also assess lymph nodes: A. on the palmar aspect of the hands. B. in the popliteal region. C. in the patellar region. D. on the dorsum of the foot.

B. in the popliteal region. The head, neck, axilla, inguinal areas, and the popliteal region are examples of lymph nodes most accessible to inspection and palpation.

Mrs. Taylor has brought her infant in for his 2-month checkup. On examination, you are concerned about hypothermia because you know: A. infants have an increased amount of stratum corneum. B. infants have decreased amounts of subcutaneous tissue. C. infants have a decreased amount of stratum germinativum. D. infants have a lanugo covering of the skin.

B. infants have decreased amounts of subcutaneous tissue. The subcutaneous fat layer is poorly developed in newborns, predisposing them to hypothermia.

When recording data into the patient's record, the health care provider must remember that the record is a: A. patient's personal and private record. B. legal document that may be used in court and other legal proceedings. C. health care organization's record that can only be used for medical treatment within that organization. D. public document that is available to those who are affiliated with the health care organization.

B. legal document that may be used in court and other legal proceedings. The patient's record is a legal document, and any information contained in it may be used in court and in other legal proceedings, as well as to make health care payment determinations.

Heart size estimated by percussion should be confirmed by: A. auscultation of the heart sounds. B. location of the apical pulse or PMI. C. palpating the left sternal border. D. palpating the heart base.

B. location of the apical pulse or PMI. If radiographic facilities are unavailable, percussion can be used to estimate the size of the heart. Begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border. Note these points with a marking pen and the outline of the heart is visually defined. On the left, the loss of resonance will generally be close to the point of maximal impulse at the apex of the heart.

A function of cerumen in the ear canal is to provide: A. vibration. B. lubrication. C. sound transmission. D. adhesiveness.

B. lubrication. The ear canal lining is protected and lubricated with cerumen, secreted by the apocrine glands in the distal third of the canal. Cerumen provides an acidic pH environment that inhibits the growth of microorganisms.

The mediastinal crunch (Hamman sign) can best be heard with the patient: A. in a supine position. B. lying on the left side. C. sitting completely upright. D. positioned with the head elevated 30 degrees.

B. lying on the left side. Mediastinal crunch (Hamman sign) is found with mediastinal emphysema. A great variety of sounds—loud crackles, clicking, and gurgling sounds—are heard over the precordium. They are synchronous with the heartbeat and not particularly so with respiration. These sounds can be more pronounced toward the end of expiration and are easiest to hear when the patient leans to the left or lies down on the left side.

The Hamman sign can best be heard when the patient is: A. in a supine position. B. lying on the left side. C. sitting completely upright. D. positioned with the head elevated 30 degrees.

B. lying on the left side. Mediastinal crunch (Hamman sign) is found with mediastinal emphysema. A great variety of sounds—loud crackles, clicking, and gurgling—are heard over the precordium. They are synchronous with the heartbeat and not particularly so with respiration. These sounds can be more pronounced toward the end of expiration and are easiest to hear when the patient leans to the left or lies down on the left side.

Mrs. Tamber presents to your office with her 3-month-old infant son. On examination, your findings include nuchal rigidity or resistance to flexion of the neck. Because of this finding you suspect: A. brain tumor. B. meningeal irritation. C. intracerebral aneurysm. D. hydrocephalus.

B. meningeal irritation. Movement should be smooth and painless and should not cause dizziness. Nuchal rigidity, resistance to flexion of the neck, may be associated with meningeal irritation.

Mr. Wilson is a 65-year-old patient who presents to your office for routine examination. Lymph nodes in healthy adults are usually: A. large and soft. B. nonpalpable or minimally palpable. C. hard and irregular. D. large and hard.

B. nonpalpable or minimally palpable. Easily palpable lymph nodes generally are not found in healthy adults. Superficial nodes that are accessible to palpation but not large or firm enough to be felt are common.

Thoracic expansion is assessed by: A. measuring the distance the diaphragm moves downward during maximal inspiration. B. observing the distance your thumbs diverge from the midspinal line during quiet and deep breathing. C. observing the symmetry of the shoulders rising during maximal inspiration and expiration. D. measuring the distance from the middle that fingers diverge toward the midaxillary line during quiet and deep breathing.

B. observing the distance your thumbs diverge from the midspinal line during quiet and deep breathing. To evaluate thoracic expansion during respiration, stand behind the patient and place your thumbs along the spinal processes at the level of the tenth rib, with your palms lightly in contact with the posterolateral surfaces. Watch your thumbs diverge during quiet and deep breathing. A loss of symmetry in the movement of the thumbs suggests a problem on one or both sides.

Arterial occlusion is characterized by: A. pale, moist skin, and absent pulses. B. pain, pallor, and pulselessness. C. pale, warm skin, and weak pulses. D. paresthesia, weak pulses, and polyarthritis.

B. pain, pallor, and pulselessness. Arteries in any location can become narrowed, leading to decreased blood flow. The reduced circulation to the tissues will lead to signs and symptoms that are related to site, degree of narrowing, ability of collateral channels to compensate, and rapidity with which the problem develops. The first sign is usually pain, followed by pallor, and then pulselessness with advanced disease.

A condition that results in progressive ischemia caused by insufficient perfusion is referred to as: A. Raynaud phenomenon. B. peripheral atherosclerotic disease. C. venous thrombosis. D. arterial aneurysm.

B. peripheral atherosclerotic disease. In peripheral atherosclerotic disease, atherosclerotic plaques narrow arterial channels resulting in decreased blood flow to tissues and resultant tissue ischemia.

The tonsils that are located near the nasopharyngeal border are the: A. laryngeal tonsils. B. pharyngeal tonsils. C. palatine tonsils. D. lingual tonsils.

B. pharyngeal tonsils. Composed principally of lymphoid tissue, the tonsils are organized as follicles and crypts; both are covered by mucous membrane. The pharyngeal tonsils, or adenoids, are located at the nasopharyngeal border.

Molding of the infant's head is caused by: A. premature closure of the fontanels. B. shifting and overlapping of the skull bones during birth. C. subperiosteal edema. D. increased cerebrospinal fluid.

B. shifting and overlapping of the skull bones during birth. The process of birth through the vaginal canal often causes molding of the newborn skull, during which the cranial bones may shift and overlap. Within days, the newborn skull usually resumes its appropriate shape and size.

Inflexible generalization about a group is: A. race. B. stereotype. C. custom. D. tradition.

B. stereotype. A stereotype is a fixed image of any group that denies the potential of originality or individuality within the group. Race is used to categorize individuals based on their continent or subcontinent of origin.

During an interview, a patient admits to feeling worthless and having a sleep disturbance for the last 3 weeks. These clues warrant exploring the possibility of: A. altered cognition. B. suicidal ideation or plan. C. substance abuse. D. panic attacks.

B. suicidal ideation or plan. A sense of sluggishness in the daily experience; disturbances in sleeping, eating, and social contact; and feelings of loss of self-worth can be clues for depression.

The tool that uses physical and neuromuscular findings to confirm the gestational age of a newborn is: A. the Keating Fetal Assessment. B. the Ballard Clinical Assessment. C. the Winslow Fetal Growth Assessment. D. all of the above.

B. the Ballard Clinical Assessment. The Ballard Gestational Age Assessment Tool evaluates six physical and six neuromuscular newborn characteristics within 36 hours of birth to establish or confirm the newborn's gestational age. Answers a, c, and d are incorrect.

Mr. Allen is a 66-year-old man who presents to your clinic for follow-up for his chronic obstructive pulmonary disease (COPD). When assessing for the presence of clubbing, the examiner specifically examines: A. the width of the nail base. B. the angle of the nail base. C. the thickness of the nail. D. the color of the nail.

B. the angle of the nail base. The average nail base angle should measure 160 degrees. In clubbing, the nail base is boggy and the angle increases and approaches or exceeds 180 degrees. Another method of assessment is the Schamroth technique. Clubbing is associated with a variety of respiratory and cardiovascular diseases, cirrhosis, colitis, and thyroid disease.

If a mistake is made in the patient record, it is suggested that a line be drawn through it so that it is still legible. The basis for this action is related to the fact that: A. no errors are allowed. B. the chart is a legal document. C. a pen is messy when used to obliterate writing. D. others may want to read what your first impressions were.

B. the chart is a legal document. The patient's record is a legal document, and any information contained in it may be used in court and in other legal proceedings, as well as to make health care payment determinations.

Temperature changes are best assessed by: A. the ulnar surface of the hand. B. the dorsal aspect of the hand. C. the tips of the fingers. D. the ventral aspect of the fingers.

B. the dorsal aspect of the hand. The dorsal surface of the hands is best for estimating temperature. Of course, this estimate provides only a crude measure; use it to compare temperature differences among parts of the body.

Mrs. Allen is a 45-year-old patient who presents to your office with complaints of visual disturbances. On examination her visual acuity is recorded as 20/60. This can be interpreted to mean that: A. the person can read at 60 feet what an average person can read at 20 feet. B. the person can read at 20 feet what an average person can read at 60 feet. C. 20% of individuals tested can read 60% of the letters in this particular line. D. out of 100 individuals, 20% can read all the letters and 60% can read half of the letters in this particular line.

B. the person can read at 20 feet what an average person can read at 60 feet. Visual acuity is recorded as a fraction in which the numerator indicates the distance of the patient from the chart (e.g., 20 feet or 6 m), and the denominator indicates the distance at which the average eye can read the line. Thus, 20/200 (6/60) means that the patient can read at 20 feet (6 m) what the average person can read at 200 feet (6 m). The smaller the fraction, the worse is the vision.

Mrs. Wolf brings her newborn in for a routine infant checkup. In the newborn examination, the focus is on: A. developmental disabilities. B. the transition to extrauterine life and congenital anomalies. C. the prenatal care of the mother and birth trauma. D. the medical history of the mother.

B. the transition to extrauterine life and congenital anomalies. With newborns the focus is on their transition to extrauterine life and the detection of any congenital anomalies.

Mrs. Starman is a 68-year-old patient who presents to your office for a routine follow-up. On examination, you notice a ring of white in the periphery of the cornea. Your assessment of the condition is that: A. the individual needs to be screened for glaucoma. B. this is a normal age-related change in the eye. C. the individual has a potentially serious complication of diabetes. D. with early intervention the progression of the deposition can be stopped.

B. this is a normal age-related change in the eye. When examining the cornea, you may note a corneal arcus (arcus senilis), which is composed of lipids deposited in the periphery of the cornea. It may in time form a complete circle (circus senilis). Note the subtle clear area between the limbus and the arcus. An arcus is seen in many individuals older than 60 years. If present before 40, arcus senilis may indicate a lipid disorder.

Which type of examination are you performing when you identify a bruit? A. Observing chest movement B. Palpating an abdomen C. Auscultating an artery D. Inspecting the skin

C. Auscultating an artery A bruit is an unexpected audible swishing sound or murmur over an artery or vascular organ. Because a bruit is a sound, it is identified by auscultation.

Stridor is usually the result of: A. a rapid collapse of lung tissue. B. air escaping from a traumatic wound to the chest. C. an obstruction high in the respiratory tree. D. uncontrolled coughing.

C. an obstruction high in the respiratory tree. Stridor is a high-pitched, piercing sound most often heard during inspiration. It is the result of an obstruction high in the respiratory tree.

Mr. Russel is a 17-year-old adolescent patient who presents with a complaint of acne. He asks the examiner why teens have more problems with acne than children. Which of the following would be an appropriate response? A. "Children have better hygiene habits than adolescents because of parental guidance." B. "Adolescents have reduced blood flow to the epidermal layer of the skin, making them more prone to infections." C. "At puberty, adolescents begin to secrete more oil from sebaceous glands." D. "Children have very little skin mass, which prevents development of acne."

C. "At puberty, adolescents begin to secrete more oil from sebaceous glands." During adolescence, the apocrine glands enlarge and become active, causing increased axillary sweating and sometimes body odor. Sebaceous glands increase sebum production in response to increased hormone levels, primarily androgen, giving the skin an oily appearance and predisposing the individual to acne.

Which statement made by a 75-year-old patient indicates a normal process of aging? A. "My tongue feels swollen." B. "My tonsils are large and sore." C. "Food does not taste the same as it used to." D. "I have white and black spots under my tongue."

C. "Food does not taste the same as it used to." Deterioration of the sense of smell results from loss of olfactory sensory neurons beginning at about 60 years of age. The sense of taste begins deteriorating at about 50 years of age as the number of papillae on the tongue and salivary gland secretion decrease, reducing the perception of sweet sensation. However, a wide variation in rate of smell and taste deterioration occurs.

Ms. Carol Turner, a 38-year-old woman, brings her 1-year-old son in for health care. Which of the following requests made would be most appropriate at the beginning of an interview? A. "Mom, please place your son in your lap." B. "Carol, please place your son in your lap." C. "Ms. Turner, please place your son in your lap." D. "Sweetie, please place your son in your lap."

C. "Ms. Turner, please place your son in your lap." Answer c best displays courtesy and respect for the parent. Initially, the examiner should address the patient or caregiver properly (e.g., as Mr., Miss, Mrs., Ms., or the manner of address preferred by the patient) and repeat the patient's name at appropriate times. Do not use a surrogate term for a person's name; for example, when the patient is a child, do not address the parent as "Mother" or "Father."

A 4-month-old infant is brought to the clinic. At birth, the baby weighed 6 pounds 8 ounces. If the baby is gaining weight at a desired rate, the examiner should expect the baby to now weigh about: A. 8 pounds. B. 9½ pounds. C. 12 pounds. D. 15 pounds.

C. 12 pounds. Most term newborns vary in weight between 2500 and 4000 g (5 lb and 8 oz to 8 lb and 13 oz). After losing up to 10% of their birth weight, newborns regain that weight within 2 weeks, and then gain weight at a rate of approximately 30 g (1 oz) per day. In general, infants double their birth weight by 4 to 5 months of age and triple their birth weight by 12 months of age.

A pregnant patient has a prepregnancy weight-to-height body mass index of 22.4. The examiner should expect this patient's weight gain during pregnancy to fall into which weight range? A. Less than 20 pounds B. 20 to 26 pounds C. 25 to 35 pounds D. 40 to 50 pounds

C. 25 to 35 pounds Women with a prepregnancy BMI of 19.8 to 26.0 should gain 11.5 to 16 kg (25 to 35 pounds) over the entire pregnancy.

When using a aneroid sphygmomanometer, the dial should face you and be no more than __________ away. A. 1 ft B. 2 ft C. 3 ft 4 ft

C. 3 ft This distance allows the aneroid sphygmomanometer to remain eye level, affording the user a more accurate reading.

Mr. Torres brings his 8-year-old son in with a complaint of sore throat. On examination, you note that the patient's tonsils are enlarged and nearly touch the uvula. This is documented as: A. 1+. B. 2+. C. 3+. D. 4+.

C. 3+. Enlarged tonsils are graded to describe their size: A, 1+, visible; B, 2+, halfway between tonsillar pillars and the uvula; C, 3+, nearly touching the uvula; D, 4+, touching each other.

Assuming that a newborn is not crying, you would expect a respiratory rate per minute of about: A. 10 to 20. B. 21 to 30. C. 40 to 60. D. 81 to 95.

C. 40 to 60. The expected rate varies from 40 to 60 respirations per minute, although a rate of 80 is not uncommon.

The costal angle is generally no greater than: A. 45 degrees. B. 60 degrees. C. 90 degrees. D. 110 degrees.

C. 90 degrees. The angle formed by the costal margins at the sternum is usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles.

Which patient demonstrates the highest risk factor for respiratory disability? A. A patient with a history of hypertension B. A child who has had a previous respiratory infection C. A patient with paraplegia D. An extremely thin female patient

C. A patient with paraplegia The patient may be less able to use the respiratory muscles because of muscle weakness, general physical disability, or a sedentary lifestyle. Being male or older; having a family history of respiratory compromise; having a history of smoking; and extreme obesity are additional barriers to normal respiratory functioning.

At which location would you auscultate to best assess the middle lobe of the right lung? A. Anterior chest B. Posterior chest C. Axilla D. Midclavicular line

C. Axilla Listen systematically at each position throughout inspiration and expiration, taking advantage of a side-to-side comparison as you move downward from apex to base at intervals of several centimeters. The sounds of the middle lobe of the right lung and the lingula on the left are best heard in the respective axillae.

Which statement is true regarding the use of abbreviations? A. The use of abbreviations is fine as long as you can interpret them. B. Abbreviations should be used as much as possible to reduce the time and space needed for documentation. C. Abbreviations should be avoided; they can be misinterpreted. D. The use of abbreviations for documentation is acceptable only in an emergency situation.

C. Abbreviations should be avoided; they can be misinterpreted. When interprofessional languages are obscured by acronyms and abbreviations, communication suffers and the safety of patients may be compromised. When considering the use of initials, abbreviations, and acronyms to get things said and written in a hurry, resist the temptation.

A palpable left supraclavicular lymph node is suggestive of which condition? A. Middle ear infection B. Mandibular abscess C. Abdominal malignancy D. Epstein-Barr mononucleosis

C. Abdominal malignancy A palpable supraclavicular node on the left (Virchow node) is a significant clue to thoracic or abdominal malignancy.

To what is the mnemonic HEEADSSS a guide? A. Developmental milestones B. Mental status C. Adolescent issues D. Substance abuse behaviors

C. Adolescent issues For adolescents, add peer group activities, conflicts, relationships, sexual activity, alcohol or illicit drug use, concerns with gender identity and independence, self-esteem, favorite activities, type of job, and potential hazards. This may be summarized with the HEEADSSS tool.

Ductus arteriosus is a defining characteristic of the fetal circulation. What is its function? A. Facilitates blood flow through the kidneys B. Increases blood supply to the liver C. Allows blood to bypass the lungs D. Diverts large amounts of oxygenated blood to the brain

C. Allows blood to bypass the lungs Fetal circulation, including the umbilical vessels, compensates for the nonfunctional fetal lungs. Blood flows from the right atrium into the left atrium via the foramen ovale. The right ventricle pumps blood through the patent ductus arteriosus rather than into the lungs.

What occurs in the first cognitive phase of stereotyping? A. Recognition of an individual as from a different ethnic group B. Plan of interaction is developed based on previous beliefs and experiences C. An individual is categorized into a social group D. Negative emotions are triggered by the patient's behavior

C. An individual is categorized into a social group Stereotyping occurs in two phases. In the first phase, a stereotype becomes activated when an individual is categorized into a social group. When this occurs, the beliefs and feelings (prejudices) come to mind about what members of that particular group are like. Over time, this first phase occurs without effort or awareness.

Which approach provides the most objective basis for determining if a patient is developing a facies associated with a particular condition or syndrome? A. Ask the patient to describe recent changes in appearance. B. Ask a family member of the patient if any changes in appearance have been noted. C. Ask the patient to show you an old photograph of himself or herself. D. Ask the patient about any changes in body image or self-esteem.

C. Ask the patient to show you an old photograph of himself or herself. Facies is defined as an expression or appearance of the face and features of the head and neck that, when considered together, is characteristic of a clinical condition or syndrome. One way to better appreciate these changes is to ask the patient to provide an old photograph of himself or herself.

Which guideline will typically guide assessment of the lymph system? A. Assess the entire lymph system at once, exploring all accessible nodes. B. Assess both superficial and deep nodes, using palpation and a Doppler. C. Assess the lymph system region by region as each body system is assessed. D. Assess the lymph nodes when the patient's history suggests a need to do so.

C. Assess the lymph system region by region as each body system is assessed. The lymphatic system is examined region by region during the examination of the other body systems (i.e., head and neck, breast and axillary, genitalia, and extremities) and by palpating the spleen. Sometimes you may perform a comprehensive lymphatic examination, exploring all the areas in which the nodes are accessible.

In which of the following situations is the pneumatic attachment of an otoscope indicated? A. Removal of excessive ear wax from an adult or child B. Inflation of the ear canal in an adult with a collapsed canal for improved viewing C. Assessment of the fluctuating capacity of the tympanic membrane D. Evaluation of the cone of light reflex in an adult or child

C. Assessment of the fluctuating capacity of the tympanic membrane The pneumatic attachment for the otoscope is used to evaluate the fluctuating capacity of the tympanic membrane.

Ms. Abbot is a 21-year-old patient who presents to your office. You suspect she has bulimia. Which of the following best describes this condition? A. Binge eating followed by excessive amounts of exercise B. Binge eating on high-calorie and high-fat foods followed by use of laxatives and diuretics C. Binge eating on high-calorie or high-carbohydrate foods followed by self-induced vomiting D. Substance abuse in late teens followed by self-induced vomiting

C. Binge eating on high-calorie or high-carbohydrate foods followed by self-induced vomiting Bulimia nervosa is an eating disorder classified by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, as psychiatric disease, the cause of which is unknown. It is characterized by episodes of binge eating, usually on high-calorie or high-carbohydrate foods, followed by purging behaviors like vomiting, laxatives, or diuretic use.

1. 29.ID: 18659195769 When palpating enlarged lymph nodes in a patient with tuberculosis, which finding would you expect? A. Warm, tender nodes B. Pulsating irregular nodes C. Body temperature, nontender nodes D. Hard, matted nodes

C. Body temperature, nontender nodes In tuberculosis, the lymph nodes, often felt in the cervical chains, are usually body temperature, soft, matted, and not tender or painful.

Which structure transports and filters air? A. Acinus B. Acromion C. Bronchus D. Stroma

C. Bronchus The tracheobronchial tree is a tubular system that provides a pathway along which air is filtered, humidified, and warmed as it moves from the upper airway to the alveoli.

Which of the following helps differentiate caput succedaneum from cephalohematoma? A. Caput occurs over the parietal bones; cephalohematoma may occur anywhere. B. Caput is rarely seen in premature infants; cephalohematoma mostly occurs in premature infants. C. Caput crosses suture lines; cephalohematoma is bound by suture lines. D. Cephalohematoma is associated with brain injury; caput generally is not.

C. Caput crosses suture lines; cephalohematoma is bound by suture lines. Cephalohematoma is a subperiosteal collection of blood and is therefore bound by the suture lines. It is commonly found in the parietal region and, unlike caput, may not be immediately obvious at birth.

A more rapid than expected weight gain in early infancy is associated with an increased risk of which type of problem in adulthood? A. Respiratory B. Endocrine C. Cardiovascular D. Renal

C. Cardiovascular A more rapid weight gain than expected during early infancy (e.g., the infant's weight percentile level keeps increasing rather than following a specific growth curve) is associated with increased cardiovascular disease risk as an adult (Singhal, 2006).

On meeting a new patient, you observe a nodding movement of the patient's head. Based on this observation, what assessment should you include as part of your examination of the patient? A. Auscultation of the parietal region of the skull for a bruit B. Percussion of the frontal bone for dullness C. Check for synchronization of the nod and the pulse D. Determination of arc of the nod

C. Check for synchronization of the nod and the pulse The patient's head should be upright and still. A horizontal jerking or bobbing motion may be associated with a tremor; a nodding movement may be associated with aortic insufficiency, especially if the nodding is synchronized with the pulse.

Which is an advantage of the APSO patient record format as opposed to the SOAP format? A. Patient record is shorter B. Record contains more data C. Clinically useful data are more accessible D. Can be used for all types of patients

C. Clinically useful data are more accessible With the APSO format, the assessment and plan is moved to the beginning of the document, with all remaining data available in the remainder of the note.

Mr. Kingman is a healthy 17 year old who presents with acute, severe chest pain. He has no history of illness or injury. Which cause of chest pain is the most logical problem to consider? A. Myocardial infarction B. Pulmonary embolus C. Cocaine use D. Unstable angina

C. Cocaine use Unlike in adults, chest pain in children and adolescents is seldom because of a cardiac problem. It is often difficult to find a cause, but trauma, exercise-induced asthma, and, even in a somewhat younger child, the use of cocaine should be among the considerations.

The finding of a "buffalo hump" fat pad is consistent with which disorder? A. Turner syndrome B. Klinefelter syndrome C. Cushing syndrome D. McCune-Albright syndrome

C. Cushing syndrome Obesity, buffalo hump fat pad, and supraclavicular and pendulous addominal fat distribution are objective signs of Cushing syndrome. Turner syndrome is characterized by short stature, webbed neck, broad chest with widely spaced nipples, cubitus valgus, low posterior hairline, misshapen or rotated ears, and a narrow palate with crowded teeth. Signs of Kleinfelter syndrome include small penis and testicles; diminished pubic, axillary, and facial hair; sexual dysfunction; enlarged breast tissue; and tall stature with abnormal body proportions. McCune-Albright syndrome is characterized by skeletal abnormalities, multiple endocrine dysfunctions including precocious puberty, visual and hearing impairments, and patches of abnormal skin pigmentation.

To which problem are older individuals more prone? A. Increased sensitivity to tastes B. Hyperactivity of the salivary glands C. Decreased salivation D. Edema of the tongue

C. Decreased salivation In the older adult, decreased saliva may cause an increase in dental caries and oral discomfort.

Incremental grading is often used for recording which examination finding? A. Size of lymph nodes B. Tenderness related to pain perception C. Deep tendon reflexes D. Amount of discharge visible from an orifice

C. Deep tendon reflexes Findings that vary by degrees are customarily graded or recorded in an incremental scale format. Pulse amplitude, heart murmur intensity, muscle strength, and deep tendon reflexes are findings often recorded in this manner.

Which of the following characteristics differentiates an erosion from an ulcer? A. Color B. Diameter C. Depth D. Classification

C. Depth An erosion results from a loss of part of the epidermis and is depressed, moist, and glistening. It follows the rupture of a vesicle or bulla. An ulcer results from the loss of epidermis and dermis. It is concave and varies in size.

After examining a patient's eyes, you are documenting your findings. Which information would you include about a finding of ptosis? A. Severity of redness and injection of the lacrimal duct based on a range of 0 to 10 B. Number of millimeters separating the upper and lower lid when the eyes are closed C. Difference in millimeters between the position of the two upper lids relative to the limbus D. Degrees of eversion of the lower lid

C. Difference in millimeters between the position of the two upper lids relative to the limbus Ptosis indicates a congenital or acquired weakness of the levator muscle or a paresis of a branch of the third cranial nerve. Record the difference between the two lids in millimeters. The average upper lid position is 2 mm below the limbus (the border of the cornea and the sclera), and the average lower lid position is at the lower limbus.

A patient has an undiagnosed tumor in the middle lobe of the right lung, which has caused atelectasis. Which finding would alert the examiner to the possibility of this problem? A. A low-pitched grating sound heard during inspiration and expiration B. Hyperresonance in the right middle lobe C. Diminished or absent breath sounds over the area of the right middle lobe D. Coarse crackles auscultated throughout the lung field

C. Diminished or absent breath sounds over the area of the right middle lobe Atelectasis is the incomplete expansion of the lung at birth or the collapse of the lung at any age. The area of the lung affected by atelectasis is airless and therefore breath sounds heard over the area are diminished or absent.

Which is a defining characteristic of a cephalohematoma? A. Located over the occiput B. Margins are poorly defined C. Does not cross suture lines D. Gradually hardens with time

C. Does not cross suture lines A cephalohematoma is a subperiosteal collection of blood and is therefore bound by the suture lines. It is commonly found in the parietal region and, unlike caput, may not be immediately obvious at birth. A cephalohematoma is firm, and its edges are well defined; it does not cross suture lines.

If recorded data are inaccurate, which action should be taken? A. Erase all information completely. B. Place the information in parentheses; sign and date. C. Draw a single line through the incorrect information; sign and date. D. Draw double or triple lines through the data so that they are unreadable.

C. Draw a single line through the incorrect information; sign and date. If using a paper chart, make necessary changes by lining out data, leaving crossed-out data legible. Initial and date the changes.

The apocrine gland responds primarily to which type of stimuli? A. Thermal B. Painful C. Emotional D. Environmental

C. Emotional The apocrine glands are specialized structures found only in the axillae, nipples, areolae, anogenital area, eyelids, and external ears. These glands are larger and located more deeply than the eccrine glands. In response to emotional stimuli, the glands secrete a white fluid containing protein, carbohydrate, and other substances.

What does a pulse amplitude of 2 indicate? A. Slightly diminished force B. Low to moderate force C. Expected force D. Full force

C. Expected force The amplitude of the pulse is described on a scale of 0 to 4. Two is an expected force, with 0 indicating absent, 1 is diminished, 3 is full, and 4 is bounding.

When you ask the patient to clench the teeth and then to smile, which cranial nerve are you testing? A. Trochlear B. Abducens C. Facial D. Vagus

C. Facial To test the facial nerve, ask the patient to clench his or her teeth and smile to observe the occlusion of the teeth. The facial nerve (cranial nerve VII) is also tested with this maneuver. Proper tooth occlusion is apparent when the upper molars fit into the groove on the lower molars and the premolars and canines interlock fully.

Ms. Rodgers is a 21-year-old woman who presents to your office with a concern about skin cancer. She tells you that she sunbathes every summer at the shore and that her mother had skin cancer. Which of the following is not a risk factor for the development of skin cancer? A. Tendency to burn easily B. Light-colored hair or eyes C. Female gender D. Age older than 50

C. Female gender Answers a, b, and d are risk factors for developing skin cancer, whereas answer c, being female, is not.

In the assessment of the child or adolescent presenting for a required school physical examination, where would you include information related to motor skills and language development? A. Personal and social history B. Medical history C. Growth and development D. Present illness

C. Growth and development Growth and development. For toddlers and young children, list motor skills and language milestones attained, age toilet trained, and age weaned from bottle.

A 45-year-old patient presents with a complaint of anxiety related to his wife's criticism of his drinking. During the history you ask several of the CAGE model questions and the patient tells you that he wants to cut down on his drinking. Which conclusion would you draw about this patient? A. He is an alcoholic. B. His drinking is caused by anxiety. C. He may be an alcohol abuser. D. He should be examined for symptoms of withdrawal.

C. He may be an alcohol abuser. The CAGE questionnaire is one model for discussing the use of alcohol. CAGE is an acronym for Cutting down, Annoyed by criticism, Guilty feeling, Eye-openers. Its use does not ensure absolute sensitivity in the detection of a problem. There is a difference between a screening and an assessment interview. The goal of screening is to find out if a problem exists. This is particularly true of CAGE, CRAFFT, and TACE screening tools. They are effective, but they are only the start, and assessment goes on from there.

During the course of the interview, a patient indicates that he has been given the drug gentamicin (an aminoglycoside antibiotic) for an upper respiratory infection. Based on this information, you would check for which type of problem? A. Dizziness and vertigo B. Recurrent nosebleeds C. Hearing loss D. Oral lesions

C. Hearing loss Hearling loss in one or both ears can result from a variety of reasons, such as medication. Ototoxic medications include aminoglycosides, gentamicin, streptomycin, quinine, cisplatin, salicylates, and furosemide.

Which information belongs in a family history? A. Chronic illness B. Current problems C. Hereditary diseases D. Personal data

C. Hereditary diseases Focus on number of miscarriages, number of deceased children, congenital anomalies, and hereditary disorders in the family.

You have been assessing Ms. Tanner for suspected valvular problems. Which finding is consistent with severe tricuspid regurgitation? A. Early prominent C wave B. Late depressed v wave C. Holosystolic murmur in the tricuspid region D. Systolic murmur in the tricuspid region

C. Holosystolic murmur in the tricuspid region Tricuspid regurgitation is the backflow of blood into the right atrium during systole. A mild degree of tricuspid regurgitation can be seen in up to 75% of the normal adult population. Those with severe cases display a holosystolic murmer in the tricuspid region.

Ms. Smith presents to your office for a physical examination and nutritional counseling. On examination, you note her waist circumference is greater than 35. What diseases are associated with this level of waist circumference? A. Arthritis B. Type 1 diabetes C. Hypertension D. Ulcerative colitis

C. Hypertension Diseases like type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease are associated with a large waist circumference (>35 inches in women).

Mr. Edwards is a 63-year-old patient with pleuritic pain and shallow respirations. What term describes abnormally shallow respirations as seen with limited excursion resulting from pleuritic pain? A. Bradypnea B. Hyperpnea C. Hypopnea D. Kussmaul breathing

C. Hypopnea Hypopnea refers to abnormally shallow respirations (e.g., when pleuritic pain limits excursion).

Which of the following statements regarding the effect of gender on health care is true? A. Individuals treated by male clinicians have lower mortality rates than those treated by female clinicians. B. Male family practice clinicians order more laboratory tests than do their female counterparts. C. Male clinicians are more likely to provide diet and exercise counseling to obese men than are female clinicians. D. Female clinicians write more prescriptions for pain medications than do their male counterparts.

C. Male clinicians are more likely to provide diet and exercise counseling to obese men than are female clinicians. In a qualitative study examining videotapes of primary care visits, compared with male physicians, women physicians were more "patient-centered" in their communication skills. The greatest amount of patient-centeredness was observed when female physicians interacted with female patients. Conversely, compared with a female physician, obese men seen by a male physician were more likely to receive diet and exercise counseling.

Which is a pregnancy-associated change that occurs within the cardiovascular system? A. Significant electrocardiographic (ECG) changes related to stress testing B. Decrease in cardiac output C. Increase in blood volume D. Axis rotation resulting in dextrocardia

C. Increase in blood volume The maternal blood volume increases 40% to 50% over the prepregnancy level. The rise mainly is due to an increase in plasma volume, which begins in the first trimester and reaches a maximum after the 30th week.

Mrs. Jones brings her 5-year-old son in for a well visit. As part of the child's examination you check for nystagmus. How do you do this? A. Assess visual acuity. B. Inspect the macula of the eye with an ophthalmoscope. C. Inspect movement of the eyes to the six cardinal fields of gaze. D. Palpate the globe while the child holds eyelids closed.

C. Inspect movement of the eyes to the six cardinal fields of gaze. Nystagmus refers to horizonatal, vertical or circular eye movements which are rapid, rhythmic, repetitious, and involuntary. Full movement of the eyes is controlled by the integrated function of the cranial nerves (CNs) III (oculomotor), IV (trochlear), and VI (abducens) and the six extraocular muscles. Do not be surprised to observe a few horizontal rhythmic movements (nystagmic beats) when checking eye movement.

Mrs. Mills is a 61-year-old patient with chronic respiratory problems. Her laboratory results demonstrate a metabolic acidosis. The respiratory pattern typically exhibited by the patient with metabolic acidosis is called: A. platypnea. B. paroxysmal nocturnal dyspnea. C. Kussmaul breathing. D. Biot respiration.

C. Kussmaul breathing. Kussmaul breathing, always deep and most often rapid, is the eponym applied to the respiratory effort associated with metabolic acidosis.

Which factor accounts for the decline in stature of an older adult? A. Increased trifold skin thickness B. Decreased weight compared with height C. Kyphosis D. Decreased muscle mass

C. Kyphosis Physical stature declines in older adults beginning at approximately 50 years of age. The intervertebral disks thin and kyphosis develops with osteoporotic vertebral compression.

Mrs. Bower is a 55-year-old patient who presents to your office with a complaint of fatigue. On palpating the precordium during her examination, a heave is identified with lateral displacement of the apical pulse. Which problem might this finding indicate? A. Mitral regurgitation B. Aortic stenosis C. Left ventricular enlargement D. Pericarditis

C. Left ventricular enlargement If the apical impulse is more vigorous than expected, characterize it as a heave or lift. An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may indicate increased cardiac output or left ventricular hypertrophy.

A 45-year-old man tells you that he often has headaches in the evening that feel like a band is being tightened around his head. These characteristics are indicative of which type of headache? A. Classic migraine B. Cluster C. Tension D. Hypertensive

C. Tension Muscular tension headaches can occur at anytime but usually present in the afternoon or evening. Patients often report bandlike constriction with stress, anger, or bruxism.

A 19-year-old man has a severe infection involving the fifth digit of the right hand. Where should the examiner expect to palpate enlarged and tender lymph nodes? A. Radial aspect of the wrist B. Palmar aspect of the hand C. Medial epicondyle of the humerus D. Left lower neck

C. Medial epicondyle of the humerus The epitrochlear lymph nodes drain the hand and lower arm. These nodes are located at the elbow in the groove between the biceps and triceps muscles proximal and slightly anterior to the medial epicondyle of the humerus.

1. Mrs. Black is bringing her adolescent daughter in for her follow-up visit. Which of the following statements is true about sexual maturation? A. Breast and pubic hair development are not related to a growth spurt. B. Sexual maturation occurs later in girls than boys. C. Mexican American girls enter puberty later than blacks and earlier than whites. D. Sexual maturation occurs later in taller girls.

C. Mexican American girls enter puberty later than blacks and earlier than whites. Sexual maturation begins earlier in girls with a higher body mass index. On average, black girls enter puberty first, followed by Mexican American girls, and then white girls.

If an infant's head circumference is smaller than the chest circumference, which of the following would be a potential cause? A. Hypopituitary dwarfism B. Hydrocephaly C. Microcephaly D. Failure to thrive

C. Microcephaly Microcephaly is suspected when an infant's head circumference is smaller than the chest circumference or the head circumference does not grow as expected and plots in lower percentile curves.

Which valve area are you listening to when you place your stethescope at the fifth left intercostal space at the midclavicular line? A. Tricuspid B. Pulmonic C. Mitral D. Aortic

C. Mitral The mitral (or apical) value can be auscultated at the apex of the heart in the fifth left intercostal space at the midclavicular line.

A newborn should be inspected for jaundice using which of the following? A. Wood's light B. Fluorescent light C. Natural light D. Black light

C. Natural light Adequate lighting is essential when assessing the newborn. Daylight provides the best illumination for determining color variations, particularly jaundice. If daylight is unavailable or insufficient, supplement it with overhead fluorescent lighting. Inadequate lighting can result in inadequate assessment.

Which finding indicates respiratory distress in the infant or young child? A. A respiratory rate of 30 breaths per minute B. An irregular respiratory pattern C. Observation of sternal and supraclavicular retractions with breathing D. Auscultation of bronchovesicular sounds throughout the lung field

C. Observation of sternal and supraclavicular retractions with breathing Infants who have a narrow tracheal lumen from compression by a congenital malformation, tumor, abscess, or double aortic arch can develop stridor. Retraction at the supraclavicular notch and contraction of the sternocleidomastoid muscles indicates significant respiratory distress.

When assessing a patient's respiratory rate, the examiner should do which of the following? A. Explain to the patient that respirations will be observed for the next minute. B. Count the number of respirations in 10 seconds and multiply by 6. C. Observe the rise and fall of the patient's chest. D. Make sure that the patient is in a supine position.

C. Observe the rise and fall of the patient's chest. Assessing the rise and fall of the chest right after counting the pulse is best. The examiner will get the most reliable result when patients are unaware their respirations are being counted because they inadvertently change their respiratory rate when they know they are being watched.

Which occurrence is generally associated with SMR 4 or breast stage 3 to 4? A. Enlargement of the areola B. Appearance of pubic hair C. Onset of menstruation D. Completion of puberty

C. Onset of menstruation Most girls have breast development before pubic hair appears. Completion of puberty is when breast stage 4 or public hair stage 5 has been reached. Menarche generally occurs in sexual maturity rate 4 or breast stage 3 to 4.

Which of the following cranial nerves directly connects the eye to the brain? A. Abducens B. Trochlear C. Optic D. Oculomotor

C. Optic The eye itself is connected to the brain by CN II, the optic nerve.

Which is an example of acute pain? A. Cancer pain B. Pain associated with anemia C. Pain after a surgical procedure D. Osteoarthritis

C. Pain after a surgical procedure Acute pain is of short duration and has a sudden onset in association with injury, surgery, or an acute illness episode. The other choices are examples of chronic pain.

How should the supraclavicular lymph nodes be assessed? A. Place the patient in a supine position, and ask the patient to hold his or her breath. B. Place the patient in the Trendelenburg position and illuminate the lymph nodes with a bright light. C. Palpate deeply behind the clavicles as the patient flexes his head forward. D. Palpate lightly below the clavicles with the patient in a sitting position.

C. Palpate deeply behind the clavicles as the patient flexes his head forward. To palpate for supraclavicular lymph nodes, the examiner encourages the patient to relax the musculature of the upper extremities so that the clavicles drop. The examiner's free hand is used to flex the patient's head forward to relax the soft tissues of the anterior neck. The fingers are hooked over the clavicle lateral to the sternocleidomastoid muscle.

Ms. Randolph, who is 74 years of age, has no known health problems or diseases. You are doing a preventive health care history and examination. Which finding is a structural variation with limited clinical significance? A. Barrel chest B. Clubbed fingers C. Pectus carinatum D. Retractions

C. Pectus carinatum Two common structural findings are pigeon chest (pectus carinatum), which is a prominent sternal protrusion, and funnel chest (pectus excavatum), which is an indentation of the lower sternum above the xiphoid process.

Which of the following examination techniques is not often done when examining the chest and lungs of a newborn? A. General survey B. Inspection C. Percussion D. Auscultation

C. Percussion The examination of the chest and lungs of the newborn follows a sequence similar to that for adults. Inspecting without disturbing the baby is key, and for this reason auscultation often occurs at the same time as inspection. Percussion may be unreliable and is typically not performed on infants. The examiner's fingers may be too large for a baby's chest, and particularly so for the premature infant.

Which abnormality found when examing the eyes of a 12 year old can be indicative of nephrotic syndrome? A. Drusen spots B. Lid fasciculation C. Periorbital edema D. Xanthelasma

C. Periorbital edema Inspect the orbital and periorbital area for edema, puffiness, or redundant tissue below the orbit. Although puffiness may represent the loss of elastic tissue that occurs with aging, periorbital edema is always abnormal; the significance varies directly with the amount. It may represent the presence of thyroid eye disease, allergies, or (especially in youth) the presence of renal disease (nephrotic syndrome).

Mr. Babson is a 74-year-old man who presents to your office with a complaint of a "spot" on his chin and wants to know whether it is cancerous. Which of the following signs or symptoms indicates a need for further medical investigation? A. The "spot" is a reddish brown color. B. The "spot" has been on his chin for 20 years. C. The "spot" bleeds easily when it is touched. D. The "spot" is slightly raised and circumscribed.

C. The "spot" bleeds easily when it is touched. A "spot" that bleeds easily when it is touched may be indicative of a more serious condition like basal cell carcinoma, the most common form of skin cancer.

In which group would a slight enlargement of the thyroid gland on ultrasound be considered a normal finding? A. Infants B. Adolescents C. Pregnant women D. Frail elderly

C. Pregnant women The fetal thyroid gland becomes functional in the second trimester. Before this time, the mother is the source of thyroid hormone, and pregnant women require increased iodine intake. As long as adequate iodine intake is maintained, the size of the thyroid will not change on physical examination. A slight enlargement may be detectible on ultrasound.

A 76-year-old woman patient has a blood pressure that consistently runs between 106 to 114 systolic and 82 to 86 diastolic. How would you categorize her blood pressure? A. Normal B. Hypotension C. Prehypertension D. Stage 1 hypertension

C. Prehypertension Prehypertension exists if the systolic blood pressure is between 120 to 139 or the diastolic is between 80 to 89. Normal systolic is less than 120 and normal diastolic is less than 80, whereas hypertension exists when the systolic is greater than 140 and the diastolic is greater than 90.

Which is the best description of pectus carinatum? A. Horizontal ribs B. Indentation of the lower sternum C. Prominent sternal protrusion D. Displaced trachea

C. Prominent sternal protrusion Two common structural findings are pigeon chest (pectus carinatum), which is a prominent sternal protrusion, and funnel chest (pectus excavatum), which is an indentation of the lower sternum above the xiphoid process.

Mrs. Broad is a 34-year-old patient who presents for a routine examination. Which is an expected finding when observing the jugular venous pulse? A. A quick, sharp pulsation observed lateral to the trachea B. A ripple-like effect that follows the course of the vein up to the angle of the jaw when a person is placed in a 45-degree angle position C. Pulsations in a distended vein that may extend into the angle of the jaw when a person is lying supine D. A crisp, quick wave that increases and decreases with the respiration cycle

C. Pulsations in a distended vein that may extend into the angle of the jaw when a person is lying supine To examine the jugular venous pulse, have the patient lie in a supine position. When the supine patient is initially placed flat, note the engorgement of the jugular veins. Gradually raise the head of the bed until the jugular venous pulsations become evident between the angle of the jaw and the clavicle. Palpating the carotid pulse helps identify the venous pulsations and distinguish them from the carotid pulsations.

Vascular areas are predisposed to appear what color during periods of excitement or anxiety? A. Pale B. Yellow C. Red D. Blue

C. Red Vascular areas appear red in color or erythematous because of increased cutaneous blood flow during periods of excitement or anxiety. Answers a, b, and d are present during other conditions.

The primary muscle mass of the heart is formed by which of the following? A. Right ventricle and right atria B. Left ventricle and left atria C. Right and left ventricles D. Right and left atria

C. Right and left ventricles The right and left ventricles together form the primary muscle mass of the heart.

Which is an example of a resolution to a problem? A. The problem has been inactive for the past five office visits. B. The patient denies that the problem exists. C. The problem has been corrected surgically. D. The manifestations of the problem have disappeared.

C. The problem has been corrected surgically. When a problem is resolved, the date of resolution should be entered and this item can then be removed from the active problem list. Surgical correction of a condition and recovery from an acute infectious process are examples of resolved problems.

Where would you place your stethescope to auscultate the aortic valve area? A. Fourth left intercostal space along the lower left sternal border B. Second left intercostal space at the left sternal border C. Second right intercostal space at the right sternal border D. Third left intercostal space at the left sternal border

C. Second right intercostal space at the right sternal border The aortic valve lies between the left ventricle and the aorta. There are five traditional auscultatory areas: aortic valve area, second right intercostal space at the right sternal border; pulmonic valve area, second left intercostal space at the left sternal border; second pulmonic area, third left intercostal space at the left sternal border; tricuspid area, fourth left intercostal space along the lower left sternal border; and mitral (or apical) area, at the apex of the heart in the fifth left intercostal space at the midclavicular line.

Mrs. Niland brings her 13-year-old daughter in for a physical examination. Which of the following rating tools would you use to determine the child's pubertal development? A. Philip pubertal rating B. Turner maturation rating C. Sexual maturity rating D. Pubertal maturation rating

C. Sexual maturity rating Sexual maturity rating (SMR) may be assigned to determine the child's overall pubertal development. This is done after the secondary sexual characteristics are examined.

Mrs. Stevens is a 72-year-old patient with a history of rheumatoid arthritis. When you ask specifically about her pain, she says that "it's just pain." Then on a scale of 1 to 10, she labels the pain an 8. What is the most likely rationale for the discrepancy? A. She rates her pain high to get extra pain medication. B. It upsets her to talk about her pain. C. She accepts the pain as natural. D. Pain is modulated in older adults.

C. She accepts the pain as natural. Response to pain is individualized because it is a physiologic, behavioral, and emotional phenomenon. Individuals have different thresholds at which pain is perceived and different pain tolerance levels. Emotions, cultural background, sleep deprivation, previous pain experience, and age are some factors that have an effect on a person's perception and interpretation of pain.

Which of the following will best facilitate an interview with a deaf person? A. Speaking loudly B. Using gestures C. Sitting or standing at eye level D. Sitting to the side of the patient

C. Sitting or standing at eye level Persons with impaired hearing often read, write, sign, and/or read lips, but you must speak slowly and enunciate each word clearly and in full view. Sitting or standing at eye level allows for full view.

Which of the following is an example of a physical, as opposed to a cultural, characteristic? A. Language B. Hair color C. Skin color D. Beliefs or attitudes

C. Skin color Skin color is an example of a physical characteristic. Answers a, b, and d are examples of cultural characteristics.

Which of the following inhibits the pituitary from releasing growth hormone? A. Growth hormone-releasing hormone B. Insulin-like growth factor C. Somatostatin D. Sex steroids

C. Somatostatin Somatostatin inhibits the secretion of both growth hormone-releasing hormone (GHRH) and thyroid-stimulating hormone. Growth hormone is secreted in pulses, with 70% of secretion occurring during deep sleep.

Atrophy of the skin is associated with the development of which of the following lesions? A. Keloids B. Lichenification C. Striae D. Excoriations

C. Striae Several variations in skin color occur in almost all healthy adults and children, including nonpigmented striae (i.e., silver or pink "stretch marks" that occur during pregnancy or weight gain), freckles in sun-exposed areas, some birthmarks, and some nevi. Atrophy of the skin involves thinning of the skin surface and loss of skin markings, resulting in a translucent and paper-like appearance. Examples of atrophy are striae and aging skin.

Mrs. Wolf is a 48-year-old patient who presents to your office with a complaint of chest pain. On examination, you note a murmur of medium pitch that fills systole. It is heard best at the apex and along the left sternal border. Which is a cause of these clinical findings? A. Aortic regurgitation B. Tricuspid stenosis C. Subaortic stenosis D. Mitral stenosis

C. Subaortic stenosis The murmur associated with subaortic stenosis is heard at the apex and along the left sternal border. The murmer fills systole, is a diamond-shaped, medium-pitched coarse thrill that is often palpable during systole at the apex and the right sternal boarder.

Mr. Anthony is a 46-year-old patient who presents to your office with a history of thyroid dysfunction. Which maneuver will you ask him to perform while palpating his thyroid gland? A. Stick out the tongue. B. Cough deeply. C. Swallow. D. Say "ah."

C. Swallow. The patient is asked to swallow when the thyroid gland is being palpated because the thyroid gland moves with swallowing, whereas the subcutaneous fat that mimics a goiter does not.

Your patient's arm is too obese to use any blood pressure cuff you have available. What is your best action? A. Use the largest cuff you have. B. Put two cuffs together to measure the blood pressure. C. Take the blood pressure on the forearm and auscultate the radial artery. D. Take the blood pressure on the forearm and auscultate the brachial artery.

C. Take the blood pressure on the forearm and auscultate the radial artery. If the patient has an obese arm, attempt to find a cuff size appropriate for the arm size. If a sufficiently large cuff is not available, wrap a standard-size cuff around the forearm and auscultate over the radial artery, which provides the best reading available for the obese patient.

The middle ear is an air-filled cavity in which of the following bones? A. Ethmoid B. Maxillary C. Temporal D. Auditory

C. Temporal The middle ear is an air-filled cavity in the temporal bone. It contains the ossicles, three small connected bones (malleus, incus, and stapes) that transmit sound from the tympanic membrane to the oval window of the inner ear. The air-filled cells of the mastoid area of the temporal bone are continuous with the middle ear.

Which change in the cardiac cycle occurs when the heart rate increases? A. The intensity of S1 also increases. B. The frequency of S4 increases. C. The duration of diastole decreases. D. The intensity of S2 decreases.

C. The duration of diastole decreases. During diastole, the ventricles dilate, drawing blood into the ventricles as the atria contract, thereby moving blood from the atria to the ventricles. When the heart is beating at a rate of 68 to 72 beats per minute, ventricular systole is shorter than diastole. As the rate increases to about 120 because of stress or pathologic factors, the two phases of the cardiac cycle tend to approximate each other in length.

When the patient sticks out his tongue as part of the oral examination, you note that it deviates to the right. How do you interpret this finding? A. The patient has had a cerebrovascular event. B. The frenulum has atrophied. C. The hypoglossal nerve is impaired. D. The patient has a congenital defect.

C. The hypoglossal nerve is impaired. When examining the hypoglossal nerve, expect the protruded tongue to be maintained at the midline. No atrophy or fasciculations should be present. Deviation to one side indicates tongue atrophy and hypoglossal nerve impairment.

During an initial interview with your patient, you ask the patient, "Can you describe that for me?" Which statement best describes the question? A. It is the most risky type of question because the patient can say anything. B. The question is asking for specific information. C. The patient has discretion about the extent of the answer. D. The answer can lead the interviewer away from the purpose of the interview.

C. The patient has discretion about the extent of the answer. The open-ended question gives the patient discretion about the extent of an answer. This is an example of a question carefully formulated to illicit an enhanced patient response.

A 2-month-old infant is brought to the clinic for immunizations. The examiner palpates enlarged inguinal nodes. What additional finding might explain the enlarged nodes? A. The mother reports that the infant suffers from colic. B. The infant's length and weight are above the 85th percentile. C. The infant has a severe diaper rash. D. A port wine stain is present on the infant's left thigh.

C. The infant has a severe diaper rash. Enlargement of the inguinal nodes suggests infection or metastatic carcinoma in the associated anatomic area.

Which events occur during the systolic phase of the cardiac cycle? A. The atria contract and the ventricles relax. B. The atria and the ventricles contract. C. The ventricles contract and the atria relax. D. The right side of the heart contracts and the left side relaxes.

C. The ventricles contract and the atria relax. The heart contracts and relaxes rhythmically, creating a two-phase cardiac cycle. During systole, the ventricles contract, ejecting blood from the left ventricle into the aorta and simultaneously from the right ventricle into the pulmonary artery.

What happens to the electrical impulses as they pass through the atrioventricular (AV) node? A. They are converted to mechanical impulses. B. Their amplitude is augmented. C. They are slightly slowed down. D. They are selectively transmitted to the Purkinje node.

C. They are slightly slowed down. An intrinsic electrical conduction system enables the heart to contract and coordinates the sequence of muscular contractions taking place during the cardiac cycle. The impulse originates in and is paced by the sinoatrial (SA) node, located in the wall of the right atrium. The impulse then travels through both atria to the AV node, located in the atrial septum. In the AV node, the impulse is delayed but then passes down the bundle of His to the Purkinje fibers, (heart muscle cells specialized for electrical conduction), located in the ventricular myocardium.

Which of the following techniques helps the examiner determine whether a palpable skin mass is filled with fluid? A. Using a Wood's lamp B. Biopsy C. Transillumination D. Noting the odor of the lesion

C. Transillumination Transillumination may be used to determine the presence of fluid in cysts and masses. Fluid-filled lesions will transilluminate with a red glow, whereas solid lesions will not.

Growth of which body region predominates during infancy? A. Head B. Arms C. Trunk D. Legs

C. Trunk During infancy, the growth of the trunk predominates. Weight gain is initially rapid, but the speed with which weight is gained decreases over the first year of life. Growth of the head predominates during the fetal period. Growth of legs predominates during childhood.

Which examination finding may be indicative of a retro-orbital tumor? A. Episcleritis B. Argyll Robertson pupil C. Unilateral exophthalmos D. Retinitis pigmentosa

C. Unilateral exophthalmos Exophthalmos is bulging of eye anteriorly out of orbit. An eye that feels very firm and resists palpation may indicate severe glaucoma or retrobulbar tumor. When exopththalmos is unilateral, a retro-orbital tumor must be considered.

For which problem are you checking when you ask a patient to stand on the toes 10 times in succession and then palpate the leg for venous distention, noting how rapidly the distention disappears? A. Deep venous thrombosis B. Atherosclerosis C. Varicose veins D. Arterial obstruction

C. Varicose veins With varicosities, the veins appear dilated and often tortuous. If varicose veins are suspected, have the patient stand on the toes 10 times in succession. Palpate the legs to feel the venous distention. When the venous system is competent, the distention of the veins disappears in a few seconds. If the distention of the veins is sustained for a longer time, suspect venous insufficiency.

Which of the following differentiates the venous system from the arterial system? A. Veins carry ventricular blood and arteries carry atrial blood. B. Veins transport nutrients and arteries transport waste material. C. Veins contain valves to keep blood flowing in one direction. D. Arteries can distend rapidly to serve as a reservoir for excess blood.

C. Veins contain valves to keep blood flowing in one direction. The structure of the arteries and veins reflects their function. The arteries are thicker, with a greater smooth muscle layer and less ability to stretch and expand (distension) from internal pressure. They are subjected to much more pressure than are the veins. The veins are less sturdy and more distensible than the arteries. Venous return is less forceful than blood flow through the arteries, and veins contain valves to keep blood flowing in one direction. If blood volume increases significantly, the veins can expand and act as a repository for extra blood. This compensatory mechanism helps diminish stress on the heart.

A sensorineural hearing loss is the result of: A. impaired conduction through the middle/external ear. B. impaired transmission of sound through the tympanic membrane. C. a defect in the inner ear that leads to distortion of sound and misrepresentation of speech. D. the impaired transmission of sound through the Eustachian tube.

C. a defect in the inner ear that leads to distortion of sound and misrepresentation of speech. Sensorineural hearing loss is reduced transmission of sound in the inner ear. Sensorineural hearing loss first occurs with high-frequency sounds and then progresses to tones of lower frequency.

Long periods of silence during an interview may indicate: A. a need for the health care provider to increase the pace of the interview. B. an inability of the patient to communicate. C. a reluctance of the patient to verbalize information. D. a need to terminate the interview because of the decreased attention of the patient.

C. a reluctance of the patient to verbalize information. Sometimes intimidated by silence, many clinicians feel the urge to break it. Be patient. Do not force the conversation. You may have to move the moment along with an open-ended question or a mild nudge. Remember, though, that silence allows the patient a moment of reflection or time to summon courage. Some issues can be so painful and sensitive that silence becomes necessary and should be allowed. Most people will talk when they are ready.

Ideally, auscultation should be carried out last, except when examining the: A. lungs. B. heart. C. abdomen. D. kidney.

C. abdomen. Auscultation should be carried out last, except with the abdominal examination, after other techniques have provided information that will assist in interpreting what you hear. When examining the abdomen, palpation is done after auscultation because palpation may alter bowel sounds.

Tactile fremitus is increased in conditions where there is: A. excess air in the lung tissue. B. an increased respiratory rate. C. an increase in lung tissue consolidation. D. concomitant crepitus.

C. an increase in lung tissue consolidation. Gentle, more tremulous fremitus than expected occurs with some lung consolidations and some inflammatory and infectious processes.

The costal angle is: A. located directly under the axillary lines. B. located at the most inferior edge of the rib cage. C. formed by the blending together of the costal margins at the sternum. D. formed by the blending together of the ribs at the vertebrae.

C. formed by the blending together of the costal margins at the sternum. The angle formed by the costal margins at the sternum. It is usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles.

Older adults with impaired visual perception and light-dark adaptation generally do better: A. with written interviews. B. in dimly lit interview rooms. C. in a well-illuminated environment. D. with a light source that reflects in their eyes.

C. in a well-illuminated environment. Impaired vision and light-dark adaptation are a problem with written interview forms. Ensure large print and ample lighting with a source that does not glare or reflect in the eyes.

The function of the turbinates in the nose is to: A. increase turbulent airflow into the posterior nasopharynx. B. provide a receptacle for excess mucus. C. increase the surface area of the nose. D. serve as a sounding board to vocalization.

C. increase the surface area of the nose. Turbinates, parallel curved bony structures covered by vascular mucous membrane, form the lateral walls of the nose and protrude into the nasal cavity. They increase the nasal surface area to warm, humidify, and filter inspired air.

The set of the ears is determined by an imaginary line that originates at the: A. bridge of the nose. B. orbital ridge. C. inner canthus. D. tip of the nose.

C. inner canthus. To check the auricle's position, draw an imaginary line between the inner canthus of the eye and the most prominent protuberance of the occiput. The top of the auricle should be at or above this line. The top of the auricle should cross the imaginary line between the inner canthus of the eye and the prominent portion of the occiput, varying no more than 10 degrees from vertical.

In a newborn infant, a small chest-to-head size ratio is usually associated with: A. maternal diabetes. B. cocaine use during pregnancy. C. intrauterine growth retardation. D. a normal finding.

C. intrauterine growth retardation. When examining the newborn, inspect the thoracic cage, noting size and shape; measure the chest circumference, which in the healthy full-term infant is usually about 30 to 36 cm, usually 2 to 3 cm smaller than the head circumference. This difference between the two increases with prematurity. An infant with intrauterine growth retardation will have a relatively smaller chest circumference compared with the head, whereas the infant of a mother with poorly controlled diabetes will have a relatively larger chest circumference.

The balance of "hot" and "cold" and its relationship to wellness is a concept that: A. is a cultural belief found in underdeveloped countries. B. has been proven to be without validity. C. is a part of the belief systems of many cultural groups. D. has led to poor sanitization practice in many areas of the world.

C. is a part of the belief systems of many cultural groups. The balance of "hot" and "cold" is a naturalistic or holistic approach that often assumes that there are external factors—some good, some bad—that must be kept in balance if we are to remain well. The balance of "hot" and "cold" is a part of the belief system in many cultural groups.

In sequencing of the examination techniques, auscultation is generally performed: A. first—because you do not want other techniques to distort sounds. B. in whatever sequence the examiner wishes. C. last—because data from other techniques will help interpret auscultated sounds. D. in a sequence that has been decided on by the examiner and patient.

C. last—because data from other techniques will help interpret auscultated sounds. Auscultation should be carried out last, except with the abdominal examination, after other techniques have provided information that will assist in interpreting what you hear.

Mr. Kooler is a 38-year-old patient who, during the Weber test, indicates that sound is heard better in one ear. This is described as: A. reinforcement. B. redirection. C. lateralization. D. predilection.

C. lateralization. Lateralization to sound occurs when sound is heard better in one ear.

Mr. Jones is a 55-year-old gentleman with diabetes. To visualize his macula, the examiner should ask Mr. Jones to: A. blink the eye several times quickly. B. lie in a supine position. C. look directly into the light of the ophthalmoscope. D. direct eye gaze on an object to the left and then to the right.

C. look directly into the light of the ophthalmoscope. The macula, or fovea, is the site of central vision. To bring it into your field of vision, ask the patient to look directly at the light of the ophthalmoscope.

Breath sounds in young children that are loud, harsh, and bronchovesicular are associated with: A. an accumulation of fluid. B. malignant tumors or solid masses. C. normal, thin chest wall structures. D. pus-filled abscesses and tumors.

C. normal, thin chest wall structures. Because of the thin chest wall, the breath sounds of the young child may sound louder, harsher, and more bronchial than those of the adult. Bronchovesicular breath sounds may be heard throughout the chest.

Which person is most at risk for developing venous thrombosis? A person: A. who smokes one pack of cigarettes per day. B. with aortic valve insufficiency. C. on bed rest for 4 days after trauma. D. with rheumatoid arthritis.

C. on bed rest for 4 days after trauma. Thrombosis can occur suddenly or gradually and with varying severity of symptoms; it can be the result of trauma or prolonged immobilization such as related to bed rest, recent surgery, or a long airplane flight.

The major landmarks of the face are the: A. eyebrows, nose, and mouth. B. frontal, zygomatic, and ethmoid arches. C. palpebral fissures and nasolabial folds. D. orbital arches and mandibular angles.

C. palpebral fissures and nasolabial folds. Major facial landmarks are the palpebral fissures and the nasolabial folds. Facial muscles are innervated by cranial nerve (CN) V and CN VII. The temporal artery is the major accessible artery of the face, passing just anterior to the ear, over the temporal muscle, and onto the forehead.

The feel of "leather rubbing on leather" describes the sensation that may be palpable with: A. crepitus. B. vocal fremitus. C. pleural friction rub. D. tactile fremitus.

C. pleural friction rub. A palpable, coarse, grating vibration, usually on inspiration, suggests a pleural friction rub caused by inflammation of the pleural surfaces. Think of it as the feel of leather rubbing on leather.

Dullness to percussion in intercostal spaces suggests the presence of: A. cor pulmonale. B. empyema. C. pneumonia. D. sickle cell disease.

C. pneumonia. Pneumonia is an inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral). When examining the patient, ask the patient to raise the arms overhead while you percuss the lateral and anterior chest. For all positions, percuss at 4- to 5-cm intervals over the intercostal spaces, moving systematically from superior to inferior and medial to lateral. Resonance, the expected sound, can usually be heard over all areas of the lungs. Hyperresonance associated with hyperinflation may indicate emphysema, pneumothorax, or asthma. Dullness or flatness suggests pneumonia, atelectasis, pleural effusion, pneumothorax, or asthma.

Mrs. Jones brings in her 2-month-old infant for a checkup. One way that a health history for an infant differs from that of an adult is the inclusion of: A. nutritional history. B. chief complaint. C. prenatal information. D. personal social information.

C. prenatal information. For older infants, record information as for adults; however, for newborns, include the details of the mother's pregnancy and any untoward events occurring since birth.

A conversation with a parent concerning a 5-year-old child: A. violates the child's need for privacy. B. is inappropriate because the child is able to talk with you. C. provides significant information about family dynamics. D. causes distrust in the child toward the examiner.

C. provides significant information about family dynamics. Family dynamics become evident during history taking and may even lead to clues that a parent is in need. Your responsibility goes beyond that for the child. Answers a, b, and d may apply to the adolescent child.

Mrs. Mills is a 39-year-old patient who presents for a routine physical examination. It is important when performing the physical examination that you, the examiner, should: A. record all of the information as it is revealed to you during the course of the examination. B. keep all of the information in your head for recording at a more convenient time and location. C. record limited information during the examination and document the entire examination as soon as possible after the examination. D. have another person in the room recording the information as you dictate the data.

C. record limited information during the examination and document the entire examination as soon as possible after the examination. Do not try to record all the details during the visit, because writing or typing must not distract your attention from the patient. Jotting down simple notes should be sufficient in preparation for the subsequent write-up, dictation, or EMR entry. It is essential to complete data recording as soon as possible after the examination while your memory for detail is fresh.

The eccrine glands are mainly responsible for: A. synthesis of eccrinolic acid. B. transport of body waste to the surface. C. regulation of body temperature. D. regulation of tissue growth and repair.

C. regulation of body temperature. The eccrine sweat glands open directly onto the surface of the skin and regulate body temperature through water secretion.

Which is the correct technique for performing a fundoscopic examination with a PanOptic ophthalmoscope? Examin the patient's: A. right eye with your right eye, and the left eye with your left eye. B. right eye with your left eye, and the left eye with your right eye. C. right and left eyes with your dominant eye. D. right and left eyes with your nondominant eye.

C. right and left eyes with your dominant eye. If using a PanOptic ophthalmoscope, you can use your dominant eye to examine both of the patient's eyes because of the increased distance between the patient and examiner. The focus wheel is adjusted with your thumb.

A common mistake made by health care professionals is to: A. acknowledge the practice of folk or herbal remedies. B. adapt health care concepts to meet the needs of individuals of other cultures. C. stereotype individuals based on their color or ethnic group. D. overestimate the ability of individuals from diverse cultures to understand health care concepts.

C. stereotype individuals based on their color or ethnic group. The use of physical characteristics (e.g., gender or skin color) to distinguish a cultural group or subgroup can be a trap. There is a sharp difference between distinguishing cultural characteristics and distinguishing physical characteristics. Do not confuse the physical with the cultural or allow the physical to symbolize the culture. To assume homogeneity in the beliefs, attitudes, and behaviors of all individuals in a particular group lead to misunderstandings about the individual. Answers a and b are actions the culturally competent health care professional should take, whereas answer d is another form of stereotyping, though not as common as stereotyping based on color.

The review of systems data related to the patient's problem is described and recorded as: A. objective data. B. systematic data. C. subjective data. D. impartial data.

C. subjective data. An interval history—including subjective status of the problem, current medications, and review of systems related to the problem—is presented in the subjective portion of the note.

A hordeolum (stye) is best described as a(n): A. infection of the eyelid. B. irritation and eversion of the eyelid. C. suppurative inflammation of the follicle of an eyelash. D. overgrowth of a Meibomian gland.

C. suppurative inflammation of the follicle of an eyelash. An acute suppurative inflammation of the follicle of an eyelash can cause an erythematous or yellow lump. This hordeolum or stye is generally caused by a staphylococcal infection.

The size of blood pressure cuff used for measuring an individual's blood pressure is determined by: A. the individual's age. B. the individual's heart rate. C. the individual's upper extremity circumference. D. the individual's head size.

C. the individual's upper extremity circumference. Cuffs are available in several sizes to match the size of the patient's limb. The correct cuff size ensures that equal pressure will be exerted around the artery, resulting in an accurate measurement.

1. 63.ID: 18659201348 Diaphragmatic excursion may be slightly elevated on the right side because of the presence of: A. the spleen. B. the right middle lobe. C. the liver. D. the stomach.

C. the liver. The diaphragmatic excursion is the movement of the thoracic diaphragm that occurs with inhalation and exhalation. The diaphragm is usually higher on the right than on the left because it sits over the bulk of the liver.

Mr. Valen is a 28-year-old patient who presents to your office with a complaint of asymmetry of the mouth. The examiner should suspect a problem with: A. the facial nerve. B. the thyroid gland. C. the peripheral trigeminal nerve. D. the salivary duct.

C. the peripheral trigeminal nerve. When facial asymmetry is present, note whether all features on one side of the face are affected or only a portion of the face, such as the forehead, lower face, or mouth. Suspect facial nerve paralysis when the entire side of the face is affected, and suspect facial nerve weakness when the lower face is affected. If only the mouth is involved, suspect a problem with the peripheral trigeminal nerve.

Indirect finger percussion involves striking the middle finger of the nondominant hand with: A. the fist. B. a percussion hammer. C. the tip of the middle finger of the dominant hand. D. a stethoscope.

C. the tip of the middle finger of the dominant hand. To perform indirect percussion, place your nondominant hand on the surface of the body with the fingers slightly spread. Place the distal phalanx of the middle finger firmly on the body surface with the other fingers slightly elevated off the surface. Snap the wrist of your other hand downward, and with the tip of the middle finger sharply tap the interphalangeal joint of the finger that is on the body surface.

A health care provider develops a cultural knowledge base to: A. anticipate the patient's adherence to a treatment plan. B. predict behaviors and attitudes. C. understand the behaviors, practices, and problems observed. D. change undesirable behavior or practices to conform to health care practice.

C. understand the behaviors, practices, and problems observed. A cultural knowledge base is developed through the process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups.

Some older adults may have sensory losses that make communication more difficult. Some degree of hearing loss is common in older adults. One action that tends to worsen hearing or communication problems is: A. positioning yourself so the patient is looking at your face. B. speaking clearly and slowly. C. using a high-pitched voice. D. avoiding noisy interviewing rooms.

C. using a high-pitched voice. Using a high-pitched voice is a form of shouting. Shouting magnifies the problem by distorting consonants and vowels. Position yourself so that the patient can see your face. Speak clearly and slowly, taking care to always face the patient while you are talking.

Mrs. Torres presents to your office and states, "The calf of my left leg has been hurting a lot lately, especially when I move my foot up and down. It also seems more swollen than the other leg." Based on these symptoms, the examiner should suspect: A. hypertension. B. venous stenosis. C. venous thrombosis. D. arterial insufficiency.

C. venous thrombosis. Venous thrombosis can occur suddenly or gradually and with varying severity of symptoms. Mrs. Torres is displaying classic symptoms of venous thrombosis. It can be the result of trauma or prolonged immobilization.

Which measure of jugular venous pressure is outside the expected normal limits? A. 3 cm H2O B. 6 cm H2O C. 9 cm H2O D. 12 cm H2O

D. 12 cm H2O The examiner would expect to see a value less than 9 when examining jugular venous pressure. This is the normal expected value.

During an interview, a patient describes abdominal pain that often awakens him at night. Which of the following responses by the interviewer would facilitate the interviewing process? A. "Constipation can cause abdominal pain." B. "Do you need a sleeping medication?" C. "Pain is always worse at night, isn't it?" D. "Tell me what you mean by 'often.'"

D. "Tell me what you mean by 'often.'" Answer d is an example of clarifying or seeking additional information by using the open-ended question. Answers a, b, and c are examples of yes or no or leading questions.

Which of the following questions may lead to an inaccurate response? A. "Where do you feel the pain?" B. "How does this situation make you feel?" C. "What happened after you noticed your injury?" D. "That was a horrible experience, wasn't it?"

D. "That was a horrible experience, wasn't it?" Answer d is an example of a leading question. The leading question is the most risky because it may limit the information provided to what the patient thinks you want to know. Questions a, b, and c are examples of direct and open-ended questions.

Cultural beliefs and behaviors that will have an effect on your assessment of the patient include which of the following? A. Diet and nutritional practices. B. The nature of relationships within a family C. Modes of communication: the uses of speech, body language, and space D. All of the above

D. All of the above Cultural beliefs, behaviors, and practices make up one's culture, which broadly reflects the whole of human behavior, including ideas and attitudes; ways of relating to one another; manners of speaking; the material products of physical effort, ingenuity, and imagination. Language is a part of the culture. So, too, are the abstract systems of belief, etiquette, law, morals, entertainment, and education.

A drawing in the medical record may be used to: A. document pulse amplitude. B. show the location of lesions. C. describe the origin of pain. D. All of the above

D. All of the above Drawings can sometimes provide a better description than words and should be used when appropriate. You do not have to be an artist to communicate information. Illustrations are particularly useful in describing the origin of pain and where it radiates and the size, shape, and location of a lesion.

The lymphatic system plays an integral role in which of the following body processes? A. Maintenance of fluid balance B. Infection control C. Absorption of fat D. All of the above

D. All of the above Functions of the lymphatic system include conserving fluid and plasma that leak from capillaries, defending the body against disease as part of the immune system, absorbing lipids from the intestinal tract, protecting the body from the antigenic substances of invading organisms, removing damaged cells from the circulation, and providing a partial, but often inefficient, barrier to the maturation of malignant cells within the body.

By which means can sensitization to latex occur? A. Contact with skin B. Contact with mucous membrane C. Airporne exposure D. All of the above

D. All of the above Sensitization to the latex proteins occurs by direct skin or mucous membrane contact or through airborne exposure.

According to the Centers for Disease Control and Prevention, the health care provider should apply infection control measures to which group of patients? A. Patients with a known infectious disease B. Patients with a possible infectious disease C. Patients who appear ill D. All patients regardless of their infectious status

D. All patients regardless of their infectious status Standard Precautions are to be used for the care of all patients in any setting in which health care is delivered. These precautions are designed to reduce the risk of infection based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents.

A waist-to-hip circumference ratio greater than 1.0 in men and 0.85 in women indicates which of the following? A. A healthy nutritional status B. A low percentage of body fat C. A large body frame D. An increased risk for disease

D. An increased risk for disease Waist circumference and waist-to-height ratio are indicators of visceral fat or abdominal obesity. Waist-to-height ratio is calculated as a ratio of the waist circumference (cm) and height (cm). It has been found to be a strong predictor for diabetes and cardiovascular disease in adults. A waist-to-height ratio greater than 0.5 is associated with increased risk.

A keloid is characterized by which of the following? A. Rough, thickened epidermis B. Linear crack in the skin C. A large nodule greater than 5 cm in diameter D. An irregularly shaped, elevated, and enlarging scar

D. An irregularly shaped, elevated, and enlarging scar A keloid is an irregularly shaped, elevated, progressively enlarging scar that grows beyond the boundaries of the wound. Keloids are caused by excessive collagen formation during healing.

Situation: Mario is a 16-year-old boy complaining of fatigue and weakness. Following are data collected by the health care provider during an interview and examination. Interview Data: Mario indicates that he keeps a busy schedule with school, basketball, and work. He has always been a good student, but he seems to be having a harder time keeping up with everything. He feels he is beginning to let his family and friends down because fatigue and weakness are interfering with his performance at school and on the basketball court. Mario does not want to quit his job because he is saving for college. When asked about other symptoms, he denies changes in appetite or abdominal problems but reports that he thinks he sometimes has a fever. Examination Data:General survey: Alert, thin male. Height 5 ft 7 in; weight 140 pounds.Skin: Skin color is pink. No evidence of bruising. No skin discoloration.Thorax: Respirations are even and unlabored, clear to auscultation. Heart rate and rhythm are regular.Abdomen: Bowel sounds auscultated. Abdomen soft, nontender, and nondistended.Musculoskeletal: Moves all extremities; symmetrical. Moves joints without tenderness.Head and neck: Enlarged and firm cervical lymph nodes in the posterior triangle. Which of the following questions is it most important to ask Mario? A. Have you had hepatitis B? B. Do you have any trouble turning your head? C. Have you had your tonsils out? D. Are the enlarged lymph nodes tender?

D. Are the enlarged lymph nodes tender? When assessing lymph nodes and conditions try to detect any hidden enlargement, and note the consistency, mobility, tenderness, size, and warmth of the nodes. A hard, fixed, painless node suggests a malignant process.

Mrs. Baker brings in her 5-year-old daughter for a routine examination. On examination, you note a systolic ejection murmur that is loud, harsh, and high in pitch heard over the second intercostal space along the left sternal border. Which problem should you suspect? A. Mitral valve prolapse B. Mitral valve stenosis C. Coarctation of the aorta D. Atrial septal defect

D. Atrial septal defect Congenital defect in the septum dividing the left and right atria charaterized by diamond-shaped systolic ejection murmur, often loud, high pitched, and harsh, heard over the pulmonic area and may be accompanied by a brief, rumbling, early diastolic murmur.

Which is a key indication of lower airway obstruction in a 2 year old? A. Barking cough B. Stridor C. Asymmetric chest movement D. Audible expiratory grunt

D. Audible expiratory grunt An audible expiratory grunt can indicate lower airway obstruction or focal atelectasis.

In which of the following situations is use of a Doppler indicated? A. Measurement of body temperature in a hypothermic patient B. Auscultation of the abdomen in a patient with hypoactive or absent bowel sounds C. Measurement of blood pressure in a patient with hypertension D. Auscultation of a nonpalpable pulse in a patient with peripheral vascular disease

D. Auscultation of a nonpalpable pulse in a patient with peripheral vascular disease Some sounds are so difficult to auscultate that a regular stethoscope will not suffice. The Doppler can be used to detect systolic blood pressures in patients with weak or difficult-to-hear sounds (e.g., patients in shock, infants, or obese persons). It is used to auscultate fetal heart activity, locate vessels, take weak pulses, and assess vessel patency. Other uses include localization of acute and chronic arterial occlusions in the extremities, assessment of deep vein thrombosis and valvular incompetency, and assessment of testicular torsion and varicocele.

When would you perform the Allen test on a patient? A. Before drawing blood from the ulnar artery B. After C. In preparation for D. Before insertion of a radial artery catheter

D. Before insertion of a radial artery catheter This test assesses the patency of the ulnar artery. Perform this test before radial artery puncture for arterial blood gas sampling or the insertion of a radial arterial catheter.

Which is the best description of cultural humility? A. Viewing each individual as a unique person and the center of care B. Identifying one's own ethnocentricity and tendencies to bias C. Using a social context perspective when interacting with ethnic minorities D. Being aware of one's own limitations in knowledge and cultural perspective along with openness to new perspectives

D. Being aware of one's own limitations in knowledge and cultural perspective along with openness to new perspectives Cultural humility involves the ability to recognize one's limitations in knowledge and cultural perspective and be open to new perspectives. Rather than assuming all patients of a particular culture fit a certain stereotype, the health care provider should view each patient as an individual.

Which statement best describes blood pressure? A. Blood pressure identifies the resting heart rate. B. Blood pressure measures the heart's muscle strength. C. Blood pressure is a central measurement of blood flow. D. Blood pressure is a peripheral measurement of cardiovascular function.

D. Blood pressure is a peripheral measurement of cardiovascular function. Blood pressure is the force of the blood against the wall of an artery as the ventricles of the heart contract and relax.

1. The appearance of secondary sexual characteristics in an 8-year-old boy followed by progressive sexual maturation can be indicative of which problem? A. Cushing syndrome B. Klinefelter syndrome C. Testicular tumor D. Brain tumor

D. Brain tumor A brain tumor or lesion (e.g., hypothalamic hamartoma) may activate the hypothalamic-pituitary-gonadal axis, with gonadotropins triggering the growth of the gonads, secretion of the sex hormones, and progressive sexual maturation. Answers a, b, and c result in different characteristics.

Mrs. Yates presents to your office with a 3-month-old infant for examination. During your examination, you note white specks scattered in a linear pattern around the circumference of the iris. Which of the following would best identify this condition? A. Lipemia, suggesting hyperlipidemia remaining from the mother after birth B. Enlarged corneas, suggesting congenital glaucoma C. Coloboma, suggesting congenital abnormalities D. Brushfield spots, suggesting Down syndrome or mental retardation

D. Brushfield spots, suggesting Down syndrome or mental retardation White specks scattered in a linear pattern around the entire circumference of the iris, called Brushfield spots, strongly suggest Down syndrome.

A patient with diabetes presents to the clinic complaining of an infected foot. On removing the patient's sock, the examiner notes an odor that resembles rotting apples. What type of infection is this consistent with? A. Pseudomonas infection B. Peritonitis C. Anaerobic infection D. Clostridium gas gangrene

D. Clostridium gas gangrene The skin, like other body parts, may have odors suggesting a variety of problems: infectious, metabolic, or neurologic. The smell of rotting apples usually indicates Clostridium gas gangrene.

Mrs. Vallens brings her young child in for a routine checkup. On examination, you notice a pulse that is stronger in the upper extremities than it is in the lower extremities. Which of the following is suggested by this clinical finding? A. Patent ductus arteriosus B. Tetralogy of Fallot C. Corrigan pulse D. Coarctation of the aorta

D. Coarctation of the aorta In coarctation of the aorta, a difference is noted in pulse amplitude between the upper extremities or between the femoral and radial pulses, or the femoral pulses are absent.

On examination of a 15-year-old patient, you find scabs on the nasal mucosa and a decrease in taste and smell. Which problem do you suspect? A. Foreign body in the nasal cavity B. Chronic allergy C. Recurrent epistaxis D. Cocaine use

D. Cocaine use When individuals nasally insufflate ("snort," "sniff") cocaine, signs of recent use include rhinorrhea, hyperemia, and edema of the nasal mucosa. White powder may still be present on the nasal hairs. Signs of chronic use include scabs on the nasal mucosa, decreased perception of taste and smell, and perforation of the nasal septum.

Females from which of the following groups are at the highest risk for eating disorders? A. Honor role students B. Teenagers who enjoy eating pizza with friends on the weekend C. Children from low-income families D. College-age students who are perfectionists

D. College-age students who are perfectionists Some risk factors for eating disorders includes preoccupation with weight, poor self-esteem, a perfectionist personality, self-image disturbances, family history of eating disorders, obesity or alcoholism, or food cravings or restrictions.

Which statement best differentiates crackles from wheezes? A. Crackles are heard on inspiration, wheezes on expiration. B. Crackles are head with a bell, wheezes with a diaphragm. C. Crackles are heard in the upper lobes, wheezes in the lower lobes. D. Crackles are discontinuous sounds, wheezes continuous sounds.

D. Crackles are discontinuous sounds, wheezes continuous sounds. A crackle is an abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinuous sounds, each lasting just a few milliseconds. The individual noise tends to be brief and the interval to the next one similarly brief. Crackles are discontinuous; rhonchi and wheezes are continuous.

The isthmus of the thyroid gland lies just below which of the following structures? A. Hyoid bone B. Thyroid cartilage C. Pyramidal cartilage D. Cricoid cartilage

D. Cricoid cartilage This isthmus lies across the trachea below the cricoid cartilage. A pyramidal lobe, extending upward from the isthmus and slightly to the left of midline, is present in about one third of the population.

Mr. Wilson is a 68-year-old gentleman who presents to your office for a routine examination. Which finding would be considered an expected effect of aging? A. Narrowed palpebral fissures B. Pulsating fontanels C. Uneven movement of the tongue D. Fibrosis of the thyroid gland

D. Fibrosis of the thyroid gland The rate of T4 production and degradation gradually decreases with aging, and the thyroid gland becomes more fibrotic.

Mr. Davids is a 67-year-old patient who presents to your office with a complaint of thickened white plaques on the tongue. These are most likely: A. Koplik spots. B. crypts. C. tongue tags. D. leukoplakia.

D. leukoplakia. A thickened white patch lesion that cannot be wiped away may be leukoplakia, a premalignant oral lesion.

Mr. Torres is a 56-year-old patient who presents for a follow-up examination with a complaint of leg pain. When documenting data for the history and examination, which guideline should be followed? A. Information from the patient may take up too much space, so summarize and simplify as much as possible to save space. B. Abbreviations and symbols save space so they should be used as much as possible. C. Use of an outline form may be confusing so it is best to avoid such a format. D. Document what the patient tells you and what you observe, rather than concluding and inferring.

D. Document what the patient tells you and what you observe, rather than concluding and inferring. Document what you observe and what the patient tells you, rather than the conclusions you interpret or infer. Keep subjective and symptomatic data in the history, making sure none gets woven into the physical findings. Physical examination findings should be the result of your observation and interpretation of the patient's description.

Mrs. Tucker is a 57-year-old patient who presents to your office for a routine physical examination. Most of her physical findings are normal. How are "normal findings" best documented? A. Write "normal" or "within normal limits" on the documentation form. B. Write "NA" (not applicable) on the documentation sheet. C. Because documentation focuses on abnormal findings, do not write anything down for normal findings. D. Document what was actually assessed in specific terms.

D. Document what was actually assessed in specific terms. Wording of findings should be precise and objective so that their meaning is clear to all health providers involved in the patient's care. Use of words such as normal, good, poor, and negative should be avoided, because these words are open to various interpretations by other examiners.

Ms. Casey is a 34-year-old woman with a developmental disability. She is accompanied by her mother, who says that she had dental surgery yesterday and her pain medication is not working. Which assessment finding is most indicative of an acute pain response? A. Inability to eat B. Decreased pulse pressure C. Hyperventilation D. Elevated blood pressure and pulse

D. Elevated blood pressure and pulse Elevated blood pressure and pulse are examples of behavioral changes that alert the practitioner of acute pain.

Which of the following lesion characteristics differentiates a macule from a papule? A. Diameter B. Contents C. Color D. Elevation

D. Elevation Maculaes are flat, circumscribed areas that change the color of the skin. Papules are elevated, firm, circumscribed areas of the skin. Both are less than 1 cm in diameter.

Which of the following factors influence the perception and interpretation of pain? A. Sleep deprivation, previous pain experience, previous pain medications B. Age, previous pain medications, sleep deprivation C. Cultural background, previous pain medications, emotions D. Emotions, sleep deprivation, age

D. Emotions, sleep deprivation, age Emotions, cultural background, sleep deprivation, previous pain experience, and age are some factors that have an effect on a person's perception and interpretation of pain.

Very young children may feel threatened by the use of a reflex hammer during examination. What could the examiner use in place of a reflex hammer that would be less threatening? A. Tuning fork B. Tongue blade C. End of stethoscope D. Examiner's finger

D. Examiner's finger Your finger can also act as a reflex hammer; this can be particularly useful when you are examining very young patients.

J.F. shares with you that he has an uncle and a brother with sickle cell disease. Where would this information best be documented? A. Chief complaint B. Medical history C. Social history D. Family history

D. Family history The pathway to detecting risk is the family history. Blood relatives in the immediate or extended family with illnesses with features similar to the patient's are an immediate concern. If a disease "runs in the family," such as sickle cell disease, ask about everyone from grandparents to cousins. A thorough and well-done family history is the essence of genomic medicine.

Which factor accounts for the majority of weight gained by a pregnant woman during the third trimester? A. Placental growth B. Increase in amniotic fluid C. Growth of maternal tissues Fetal growth

D. Fetal growth Maternal tissue growth accounts for most of the weight gained in the first and second trimesters. Fetal growth accounts for most weight gained during the third trimester. Placental and increase in amniotic fluid growth are part of the maternal tissue growth that accounts for weight gained in the first and second trimesters.

What are you checking when you perform an Allen test on a patient? A. Response of arterial blood flow to exercise B. Tolerance of the venous system to compression C. Risk for thrombophlebitis D. Patency of the ulnar artery

D. Patency of the ulnar artery This test assesses the patency of the ulnar artery.

Which interviewer behavior would least contribute to decreasing tension in an anxious patient? A. Avoid information overload. B. Slow the conversation. C. Maintain a calm demeanor. D. Finish the interview promptly.

D. Finish the interview promptly. Answer d is an inappropriate response and may increase the patient's level of anxiety. The examiner helps decrease anxiety by avoiding an overload of information, pacing the conversation, and presenting a calm demeanor.

Which factor is an indicator of a newborn's maturity? A. Motor skills B. Recumbent length C. Head circumference D. Gestational age

D. Gestational age Gestational age is an indicator of a newborn's maturity and is used to evaluate an infant's developmental progress. Answers a, b, and c are used to measure other characteristics from infancy to 24 years.

The radial pulse is most often used as a screening measure that evaluates which factor? A. Cardiac output B. Arterial integrity C. Arterial conductivity D. Heart rate

D. Heart rate Pulse rates are best palpated over an artery close to the surface of the body that lies over bones. The radial pulse is most often used because it the most accessible and least intrusive to the patient's personal space.

You note when examining a 62-year-old patient that when she closes her eyes, the lids tremor. This finding would cause you to carefully assess for other symptoms of which disorder? A. Bell's palsy B. Pituitary tumor C. Acoustic neuroma D. Hyperthyroidism

D. Hyperthyroidism Examine the patient's lightly closed eyes for fasciculations or tremors of the lids, a sign of hyperthyroidism.

Mr. Harold is a 47-year-old patient who presents to your office with a complaint of fatigue. The examiner is palpating the superior superficial inguinal lymph nodes on Mr. Harold. Where is the examiner palpating? A. At the lateral aspect of the groin B. Just above the groin along the base of the pelvic bone C. Between the femoral artery and femoral vein D. In the groin over the inguinal canals

D. In the groin over the inguinal canals Lymph nodes usually occur in groups. Superficial nodes are located in subcutaneous connective tissues, and deeper nodes lie beneath the fascia of muscles and within the various body cavities. The superior superficial inguinal (femoral) nodes are close to the surface over the inguinal canals. The inferior superficial inguinal nodes lie deeper in the groin.

Which issue has most recently challenged the health care system in regard to the accuracy of patient records? A. Inclusion of detailed family and background data B. Access to the record by multiple health care professionals C. EMR recording errors by students in the health care delivery area D. Inappropriate use of the CPCF function

D. Inappropriate use of the CPCF function Although potentially being a very effective tool, the ability to easily copy and paste or carry forward (CPCF) text from one note to another has become the latest hazard in electronic medical documentation. Whereas legibility is no longer an issue with electronic medical records (EMRs), copy and paste is now looming as a patient safety, legal, and regulatory challenge for EMRs. When CPCF is used inappropriately, it can affect patient safety by rendering meaningless an essential communication tool relied on at the point of care.

During what age period is the xiphoid process more prominent, more moveable, and more cartilaginous? A. Adolescence B. Adulthood C. Older adulthood D. Infancy

D. Infancy The newborn's xiphoid process is more mobile and prominent than that of the older child or adult. It has a sharp inferior tip that moves slightly back and forth under your finger. The relatively thin chest wall of the infant and young child makes the bony structure more prominent than in the adult. It is more cartilaginous and yielding, and the xiphoid process is often more prominent and more movable.

Which statement applies to infection control practice in an outpatient setting? A. Transmission-Based Precautions are implemented for all patients. B. The exclusive focus of infection control is the protection of the health care provider. C. Infection control practices may not be necessary depending on the type of outpatient service provided. D. Infection control practice is applicable to all patients in all health care settings.

D. Infection control practice is applicable to all patients in all health care settings. Standard Precautions are to be used for the care of all patients in any setting in which health care is delivered.

What would you do to differentiate clubbed nails from curved nails? A. Palpate the nail beds. B. Inspect the shape of the nail. C. Inspect the nail plate. D. Inspect the nail/base angle.

D. Inspect the nail/base angle. The average nail base angle should measure 160 degrees. In clubbing, the nail base is boggy and the angle increases and approaches or exceeds 180 degrees. One method of assessment is the Schamroth technique.

What is your conclusion when you find gingival enlargement in a pregnant patient? A. It signals periodontal disease. B. It may indicate a vitamin deficiency. C. It is suggestive of gestational diabetes. D. It is a normal finding.

D. It is a normal finding. Epulis, a localized gingival enlargement or granuloma, is usually an inflammatory rather than neoplastic change. Gingival enlargement occurs with pregnancy, puberty, vitamin C deficiency, with certain medications (e.g., phenytoin, cyclosporine, and calcium channel blockers), and in leukemia.

How would you differentiate between a respiratory and a cardiac friction rub? A. Compare the sounds heard through the anterior and posterior chest. B. Determine if the sound is louder on inspiration or expiration. C. Compare sounds at rest and after running in place to increase the pulse. D. Listen to the chest while the patient holds his or her breath.

D. Listen to the chest while the patient holds his or her breath. The respiratory rub disappears when the breath is held; the cardiac rub does not.

Which of the following behaviors is most important in establishing a connection with the patient? A. Documenting data from the history using direct patient quotes B. Phrasing questions so that they are clear and explicit C. Avoiding the trap of giving advice during an interview D. Listening intently while observing nonverbal cues

D. Listening intently while observing nonverbal cues Establishing a connection with the patient is essential to good communication. Being a skilled listener and being alert to patients' nonverbal communication help establish meaningful connections.

Mr. Lukas is a 48-year-old patient with diabetes and hypertension. Which heart sound heard on auscultation suggests a pathologic condition and requires additional evaluation? A. Split S1 B. Split S2 C. Soft S3 D. Loud S4

D. Loud S4 S3 and S4 may or may not be present. Their absence is not an unusual finding, and their presence does not necessarily indicate a pathologic condition. Thus, evaluate S3 and S4 in relation to other sounds and events in the cardiac cycle. A loud S4 always suggests a pathologic condition and deserves additional evaluation.

What condition would cause a child to have an arm-span measurement greater than his height? A. Failure to thrive B. Turner syndrome C. Acromegaly D. Marfan syndrome

D. Marfan syndrome The arm-span measurement is not routinely obtained but may be useful when evaluating a child with tall stature. The arm span should equal the child's height or stature. Arm span that exceeds height is associated with Marfan syndrome.

Situation: Mario is a 16-year-old boy complaining of fatigue and weakness. Following are data collected by the health care provider during an interview and examination. Interview Data: Mario indicates that he keeps a busy schedule with school, basketball, and work. He has always been a good student, but he seems to be having a harder time keeping up with everything. He feels he is beginning to let his family and friends down because fatigue and weakness are interfering with his performance at school and on the basketball court. Mario does not want to quit his job because he is saving for college. When asked about other symptoms, he denies changes in appetite or abdominal problems but reports that he thinks he sometimes has a fever. Examination Data:General survey: Alert, thin male. Height 5 ft 7 in; weight 140 pounds.Skin: Skin color is pink. No evidence of bruising. No skin discoloration.Thorax: Respirations are even and unlabored, clear to auscultation. Heart rate and rhythm are regular.Abdomen: Bowel sounds auscultated. Abdomen soft, nontender, and nondistended.Musculoskeletal: Moves all extremities; symmetrical. Moves joints without tenderness.Head and neck: Enlarged and firm cervical lymph nodes in the posterior triangle.You consider the possibility of Hodgkin disease. Which other characteristic of the cervical lymph nodes would be most consistent with this diagnosis? A. Gritty and warm to touch B. Symmetrically enlarged on the right and left neck C. Painful on movement or palpation D. Matted and rubbery in consistency

D. Matted and rubbery in consistency Hodgkin lymphoma is a malignant lymphoma. Matted nodes feel connected and seem to move as a unit. In Hodgkin lymphoma, nodes may be matted and firm, almost rubbery.

Mrs. Lukin is a 46-year-old patient who complains of seasonal allergies. During her examination, which of the following pairs of sinuses are accessible for physical examination? A. Ethmoid and sphenoid B. Maxillary and sphenoid C. Frontal and ethmoid D. Maxillary and frontal

D. Maxillary and frontal Only the maxillary and frontal sinuses are accessible for physical examination. The maxillary sinuses lie along the lateral wall of the nasal cavity in the maxillary bone. The frontal sinuses which develop during childhood are in the frontal bone superior to the nasal cavities.

A disruption to the flow of blood into, through, or out of the heart produces which cardiac sound? A. Protodiastolic gallop B. Friction rub C. Extra heart sound (S3/S4) D. Murmur

D. Murmur Heart murmurs are relatively prolonged extra sounds heard during systole or diastole. They often indicate a problem. Murmurs are caused by some disruption in the flow of blood into, through, or out of the heart.

Which term describes behavior approved by group standards? A. Rituals B. Values C. Beliefs D. Norms

D. Norms Norms tell us how to place individuals in relation to one another according to some agreed on and standardized measure; however, norms may not be consistent across cultures.

Mrs. Yates brings in her 14-year-old adolescent for a physical examination. On examination, you note a body mass index greater than the 95th percentile. Which of the following would you expect? A. Hyperlipidemia B. Follicular hyperkeratosis C. Prader-Willi syndrome D. Obesity

D. Obesity Obesity is excessive proportion of total body fat. It is diagnosed in children and adolescents 2 to 18 years old who have a BMI at the 95th percentile or greater for age and gender or for a BMI greater than 30.

For which age group is a functional assessment most critical? A. Children B. Adolescents C. Adults D. Older adults

D. Older adults Quite simply, functional assessment is an attempt to understand a patient's ability to achieve the basic activities of daily living. This assessment should be made for all older adults and for any person limited by disease or disability, acute or chronic.

Mrs. Housman is a 55-year-old woman with dark skin. She is concerned about her liver because she has had hepatitis in the past. In which of the following areas would jaundice be easiest to detect? A. Deep inner folds of the skin B. Earlobes C. Nasal turbinates D. Sclera

D. Sclera Color hues in dark-skinned persons are best seen in the sclera, conjunctiva, buccal mucosa, tongue, lips, nail beds, and palms. Be aware, however, that heavily callused palms in dark-skinned persons have an opaque yellow cast.

Which of the following is an example of a cultural characteristic? A. Gender type B. Habitual drinking C. Skull size D. Shared belief

D. Shared belief Culture, in its broadest sense, reflects the whole of human behavior, including ideas and attitudes; ways of relating to one another; manners of speaking; and the material products of physical effort, ingenuity, and imagination. Language is a part of the culture. So, too, are the abstract systems of belief, etiquette, law, morals, entertainment, and education. Within the cultural whole, different populations may exist in groups and subgroups.

Mrs. Harris brings her 12-year-old daughter with Down syndrome to your office for a follow-up examination. Which of the following skin characteristics is associated with Down syndrome? A. Acrocyanosis B. Supernumerary nipples C. Mongolian spots D. Simian line (crease)

D. Simian line (crease) The most commonly recognized pattern seen in children with Down syndrome is a single transverse crease in the palm.

In which patient would a resting pulse rate of 58 likely be an expected finding? A. Six year old taking an antipyretic B. Primigravida at term C. Healthy, active adult D. Sixty year old taking a beta blocker

D. Sixty year old taking a beta blocker The average resting heart rate in adults ranges between 60 and 100 beats per minute. Well-conditioned athletes or individuals taking beta blockers may have a resting pulse rate of 50 to 60 beats per minute. Adults taking beta blockers have slower heart rates that beat with less force, thus reducing blood pressure.

Which instruction would you give a patient during inspection of his or her neck? A. Hold your breath. B. Clench your teeth. C. Look up toward the ceiling. D. Swallow.

D. Swallow. Inspect the neck in the usual anatomic position, in slight hyperextension, and as the patient swallows.

Mr. Becker is a 59-year-old patient who presents to your office with chronic respiratory problems. What term would you use to document a respiratory rate greater than 20 per minute in this patient? A. Dyspnea B. Orthopnea C. Platypnea D. Tachypnea

D. Tachypnea Tachypnea is a persistent respiratory rate greater than 20 breaths per minute in an adult. Confirm that the respiratory rate is persistent.

Mr. Tucker is a 65-year-old patient who presents to your office with a complaint of right-sided, throbbing headache, usually occurring in the morning. On examination, you note the presence of thickening and tenderness of the temporal artery. Which of the following best describes these findings? A. Cluster headache B. Occipital arteritis C. Migraine headache D. Temporal arteritis

D. Temporal arteritis Temporal arteritis is characterized by daily, throbbing headache, which can be unilateral or bilateral and last hours or days. It occurs in older adults. A bruit is highly suggestive of a vascular anomaly and can be associated with temporal arteritis.

When examing a neonate, a thrill is felt over the lower left sternal border. This finding is consistent with which anomaly? A. Atrial septic defect B. Ventricular septal defect C. Patent ductus arteriosus D. Tetralogy of Fallot

D. Tetralogy of Fallot Tetralogy of Fallot is a congenital heart condition composed of four cardiac defects: ventricular septal defect, pulmonic stenosis, dextroposition of the aorta, and right ventricular hypertrophy. A common finding is a thrill during systole appreciated at the left lower sternal boarder.

Which of the following situations is an indication for transillumination? A. The patient complains of epistaxis. B. The patient has crepitus with jaw movement. C. The parotid gland is palpable and tender. D. The patient complains of pain over the sinuses with palpation.

D. The patient complains of pain over the sinuses with palpation. Expect no tenderness or swelling over the soft tissue. Swelling, tenderness, and pain over the sinuses may indicate infection or obstruction. Transillumination of the frontal and maxillary sinuses may be performed if sinus tenderness is present or infection is suspected.

Mrs. Tomberg brings her 4-day-old infant to your office with a concern of a yellowish skin tone. Which of the following statements best describes the rationale for the skin tone? A. Increased formation of subcutaneous tissue causes a yellow hue. B. Capillaries broken during the birth process turn the skin slightly yellow as bruises heal. C. The yellowish color results from increased fat metabolism and heat production. D. The infant has hyperbilirubinemia.

D. The infant has hyperbilirubinemia. Hyperbilirubinemia, or physiologic jaundice, is present to a mild degree in many newborn infants. It usually starts after the first day of life and disappears by the eighth to tenth day but may persist for as long as 3 to 4 weeks. Intense and persistent jaundice suggests liver disease, a hemolytic process, or severe, overwhelming infection.

Which of the following findings suggests that a patient has a fungal infection of the nail beds? A. The nail bed is wide and thick. B. The nail plate has a central depression, causing a spoon appearance. C. Superficial white spots are present in the nail plate. D. The nail plate is yellow and crumbling.

D. The nail plate is yellow and crumbling. Onychonyocosis is a fungal infection of the nail that commonly presents as a crumbling as the fungus grows.

As the chest of a newborn is examined, bowel sounds are auscultated in the chest. What is the significance of this finding? A. This is a normal finding in newborns. B. This is an abnormal, but benign, finding in children until 2 years of age. C. This is abnormal and possibly indicates an enlarged liver. D. This is abnormal and possibly indicates a diaphragmatic hernia.

D. This is abnormal and possibly indicates a diaphragmatic hernia. The result of an imperfectly structured diaphragm occurs once in slightly more than 2000 live births. It is suspected if gastrointestinal gurgling sounds are persistently heard in the chest, but wide transmission of these sounds can sometimes be deceptive.

What structure can be displaced by atelectasis, pleural effusion, or thyroid enlargement? A. Aorta B. Esophagus C. Sternum D. Trachea

D. Trachea In atelectasis the trachea deviates ipsilaterally. Thyroid enlargement or pleural effusion may cause the trachea to deviate away from the affected side. Pneumothorax can make the trachea go either way depending on whether there is a tension pneumothorax. In this case, pressure builds up on the side of the collapsed lung, and the deviation is away from the affected side. In contrast, with a simple collapsed lung, the trachea deviates to the affected side.

In addition to severe respiratory distress, which finding is indicative of a pneumothorax with mediastinal shift? A. Hemoptysis B. Pleural friction fremitus C. Vesicular lung sounds over the peripheral lung field D. Tracheal deviation away from the midline position

D. Tracheal deviation away from the midline position A mediastinal shift with tracheal deviation away from the involved side can be seen with a tension pneumothorax.

Mr. Booker is a 44-year-old patient who presents for routine examination. On examination, you suspect an enlarged lymph node but are unsure. Which examination method is used to differentiate an enlarged lymph node from a cyst? A. Palpation B. Auscultation for a bruit C. Biopsy D. Transillumination

D. Transillumination When you are uncertain of the nature of the findings, check whether any large mass transilluminates; as a rule, nodes do not and fluid-filled cysts do.

Which is a reason why the diaphragm of the stethoscope is better than the bell for auscultation of the lungs? A. Amplifies all types of sounds B. Filters extraneous sounds C. Pinpoints focal sound areas D. Transmits high-pitched sounds

D. Transmits high-pitched sounds The diaphragm of the stethoscope is usually preferable to the bell for listening to the lungs because it transmits the ordinarily high-pitched sounds better and because it provides a broader area of sound.

Which two muscles allow movement and provide support to the head and neck? A. Pectoralis and coracobrachial B. Trapezius and pectoralis C. Sternocleidomastoid and coracobrachial D. Trapezius and sternocleidomastoid

D. Trapezius and sternocleidomastoid The neck is formed by the cervical vertebrae, ligaments, and sternocleidomastoid and trapezius muscles, which give it support and movement.

As a component of palpation, which surface is most sensitive to vibration? A. Fingertips B. Heel of the hand C. Dorsal surface of the hand D. Ulnar surface of the hand

D. Ulnar surface of the hand The ulnar surface of the hand and fingers is the most sensitive area for distinguishing vibration.

Slow or repeated inflation of the blood pressure cuff will cause inaccurate reading as a result of which effect? A. Arterial spasms B. Muscle strain C. Vascular insufficiency D. Venous congestion

D. Venous congestion Slow or repeated inflation of the blood pressure causes sluggish venous flow, also known as venous congestion, which results in inaccurate blood pressure readings.

Mrs. Alexander is a 36-year-old patient who has asthma. On auscultation of the lungs, you hear a musical squeaking noise. What term do you use when documenting this finding? A. Friction rub B. Rales C. Rhonchi D. Wheezing

D. Wheezing Wheezing is a musical noise sounding like a squeak most often heard continuously during inspiration or expiration, usually louder during expiration.

At which age does a neonate return to his or her weight at birth? A. Within 3 days B. Within a week C. Within 10 days D. Within 2 weeks

D. Within 2 weeks After losing up to 10% of their birth weight, newborns regain that weight within 2 weeks and then gain weight at a rate of approximately 30 g (1 oz) per day.

Mrs. Harris brings her 5-year-old son to the emergency department with complaints of abdominal pain. Which tool would you use to best help the child identify his level of pain? A. Individualized numeric scale B. Descriptive pain intensity scale C. Infant pain profile D. Wong-Baker FACES Rating Scale

D. Wong-Baker FACES Rating Scale The Wong-Baker FACES Rating scale is the appropriate choice for a 5 year old's level of understanding and has been validated and proven reliable for assessing pain in children.

The jugular venous pulse is: A. a reflection of left-sided heart activity. B. an indirect measurement of systemic blood pressure. C. a direct measurement of ventricular contractility. D. a reflection of right-sided heart activity

D. a reflection of right-sided heart activity The jugular pulse is reflected back from the right side of the heart rather than pushed forward by the left side of the heart. The level at which the jugular venous pulse is visible gives an indication of right atrial pressure.

Mrs. Wheeler is a 64-year-old patient who presents to your office. She tells you that she has a vitamin B12 deficiency. The examiner can easily detect this by observing: A. a geographic tongue. B. a black hairy tongue. C. purplish swellings under the tongue. D. a smooth tongue.

D. a smooth tongue. A smooth red tongue with a slick appearance may indicate a vitamin B12 deficiency.

Situation: Mario is a 16-year-old boy complaining of fatigue and weakness. Following are data collected by the health care provider during an interview and examination. Interview Data: Mario indicates that he keeps a busy schedule with school, basketball, and work. He has always been a good student, but he seems to be having a harder time keeping up with everything. He feels he is beginning to let his family and friends down because fatigue and weakness are interfering with his performance at school and on the basketball court. Mario does not want to quit his job because he is saving for college. When asked about other symptoms, he denies changes in appetite or abdominal problems but reports that he thinks he sometimes has a fever. Examination Data:General survey: Alert, thin male. Height 5 ft 7 in; weight 140 pounds.Skin: Skin color is pink. No evidence of bruising. No skin discoloration.Thorax: Respirations are even and unlabored, clear to auscultation. Heart rate and rhythm are regular.Abdomen: Bowel sounds auscultated. Abdomen soft, nontender, and nondistended.Musculoskeletal: Moves all extremities; symmetrical. Moves joints without tenderness.Head and neck: Enlarged and firm cervical lymph nodes in the posterior triangle. Findings that deviate from normal and suggest the need for further investigation include: A. fatigue. B. weakness. C. enlarged lymph nodes. D. all of the above.

D. all of the above. Mario's fatigue, weakness, and enlarged lymph nodes are not normal findings in the adolescent and warrant additional assessment.

Situation: Mario is a 16-year-old boy complaining of fatigue and weakness. Following are data collected by the health care provider during an interview and examination. Interview Data: Mario indicates that he keeps a busy schedule with school, basketball, and work. He has always been a good student, but he seems to be having a harder time keeping up with everything. He feels he is beginning to let his family and friends down because fatigue and weakness are interfering with his performance at school and on the basketball court. Mario does not want to quit his job because he is saving for college. When asked about other symptoms, he denies changes in appetite or abdominal problems but reports that he thinks he sometimes has a fever. Examination Data:General survey: Alert, thin male. Height 5 ft 7 in; weight 140 pounds.Skin: Skin color is pink. No evidence of bruising. No skin discoloration.Thorax: Respirations are even and unlabored, clear to auscultation. Heart rate and rhythm are regular.Abdomen: Bowel sounds auscultated. Abdomen soft, nontender, and nondistended.Musculoskeletal: Moves all extremities; symmetrical. Moves joints without tenderness.Head and neck: Enlarged and firm cervical lymph nodes in the posterior triangle. The problem(s) that Mario may have include(s): A. chronic infection. B. lymphoma. C. other malignancy. D. all of the above.

D. all of the above. Mario's symptoms warrant further testing because they indicate a more serious process. His signs and symptoms accompany a variety of conditions.

Mrs. Lineman brings her 6-week-old infant in for a follow-up examination. On examination, you observe a tympanic membrane lacking conical appearance and with a diffuse light reflex. These findings: A. indicate a congenital abnormality. B. suggest a ruptured tympanic membrane. C. are classic signs of otitis media in the neonate. D. are normal for an infant of this age.

D. are normal for an infant of this age. The tympanic membrane is usually in an extremely oblique position in the newborn. Because the tympanic membrane does not become conical for several months, the light reflex may appear diffuse.

The patient tells the examiner, "I have been coughing up a lot of yellowish-green phlegm." The examiner should suspect: A. viral infection. B. tuberculosis. C. pulmonary edema. D. bacterial pneumonia.

D. bacterial pneumonia. Yellow-green sputum is an example of a characteristic that can aide the examiner in making a differential diagnosis of bacterial infection like pneumonia.

The tonsils located near the base of the tongue are the: A. laryngeal tonsils. B. pharyngeal tonsils. C. palatine tonsils. D. lingual tonsils.

D. lingual tonsils. The lingual tonsils are located near the base of the tongue. Defensive responses to inhaled and intranasal antigens are activated in these tissues.

During pregnancy, which of the following occurs to create increased susceptibility to infection? Shift from: A. immunocompetent to effector-mediated immunity B. effector immunity to cell-mediated immunity C. antibody production to cell-mediated immunity D. cell-mediated to antibody production

D. cell-mediated to antibody production Uterine contractility decreases and macrophages produce cytokines beneficial to growth of the trophoblast. A balance results. The shift from cell-mediated immunity to antibody production/humoral immunity results in increased maternal susceptibility to certain infectious diseases. However, pregnancy can lead to remission of maternal autoimmune/inflammatory diseases (e.g., rheumatoid arthritis).

Tangential lighting is important for inspection because it allows you to observe: A. the deeper cavities/folds of the body. B. changes in skin color. C. masses and/or fluid in body cavities. D. contours and variations of body surfaces.

D. contours and variations of body surfaces. Secondary, tangential lighting from a lamp that casts shadows is also important for observing contour and variations in the body surface.

The outer layer of the eye is composed of the sclera posteriorly and the _______________anteriorly. A. choroid B. lens C. conjunctiva D. cornea

D. cornea The outer wall of the eye is composed of the sclera posteriorly and the cornea anteriorly.

The best time to evaluate vocal resonance on a young child is while the child is: A. lying down, asleep. B. lying down, awake. C. sitting quietly in a parent's lap. D. crying.

D. crying. The spoken voice transmits sounds through the lung fields that may be heard with the stethoscope. Seize the opportunity that a crying child presents. A sob is often followed by a deep breath. The sob itself allows the evaluation of vocal resonance.

When sound is intensified, there is a nasal quality to the voice, and es sound like as. This is called: A. resonance. B. bronchophony. C. pectoriloquy. D. egophony.

D. egophony. When the intensity of the spoken voice is increased and there is a nasal quality (e.g., es become stuffy, broad as), the auditory quality is called egophony.

When you repeat a patient's answer, you are: A. testing the patient's knowledge. B. teaching the patient new medical terms. C. discouraging an emotional outburst. D. encouraging more detail.

D. encouraging more detail. When you repeat a patient's answer, you are engaging in reflecting. Reflecting encourages patients to provide more detail.

While interviewing an angry patient, you start to become annoyed and are beginning to dislike the patient. The best way to resolve this is to: A. spend the least amount of time possible with the patient. B. displace your annoyance toward the patient on an inanimate object. C. ignore the feelings and remain neutral in your interactions. D. express concern and explore the problem with the patient.

D. express concern and explore the problem with the patient. When dealing with the angry patient, it is appropriate to confront or acknowledge the anger and explore the potential issue. Answer d is the best example in the scenario given.

The lymph fluid flows more readily with: A. increased collecting ducts. B. greater perfusion of microscopic tubules. C. decreased superficial nodes. D. greater permeability of capillary walls.

D. greater permeability of capillary walls. As lymph fluid volume increases, it flows faster in response to mounting capillary pressure, greater permeability of the capillary walls of the cardiovascular system, increased bodily or metabolic activity, and mechanical compression. Conversely, mechanical obstruction will slow or stop the movement of lymph, dilating the system.

A patient with diabetes comes into the medical clinic, stating that he has noticed a sore on his foot for the last week. You note that his last visit was 2 months ago. You would conduct a(n): A. complete history. B. focused history. C. problem-oriented history. D. interim history.

D. interim history. The interim history is designed to chronicle events that have occurred since your last meeting with the patient. Its substance is determined by the nature of the problem and the need of the moment. The interim history should always be complemented by the patient's previous record.

The examiner notes hyperkeratosis on a patient's palms and soles. The examiner recognizes that this: A. may be a sign of a systemic disorder. B. may be an indication of a congenital heart defect. C. is commonly found among individuals with Down syndrome. D. is considered a normal finding.

D. is considered a normal finding. Hyperkeratosis or callus is a superficial area that occurs on the weight-bearing areas of the feet and on the palmar surface of the hands. Calluses are less well demarcated than corns and are usually not tender.

The use of physical characteristics to predict health care beliefs about an individual: A. is encouraged when conducting a health interview. B. provides insight into appropriate treatment. C. helps develop rapport. D. is erroneous thinking on the part of the health care provider.

D. is erroneous thinking on the part of the health care provider. The use of physical characteristics (e.g., gender or skin color) to distinguish a cultural group or subgroup is inappropriate. There is a sharp difference between distinguishing cultural characteristics and distinguishing physical characteristics. Do not confuse the physical with the cultural or allow the physical to symbolize the cultural. To assume homogeneity in the beliefs, attitudes, and behaviors of all individuals in a particular group leads to misunderstandings about the individual. Answers a, b, and c are inaccurate and may serve as prejudicial factors in the care provided.

Developing cultural awareness and sensitivity is vital for the examiner to succeed at: A. applying statistical trends of various ethnic and cultural groups. B. performing a physical examination. C. identifying patients at high risk for various diseases. D. recognizing and accepting beliefs about health that differ from personal beliefs.

D. recognizing and accepting beliefs about health that differ from personal beliefs. Cultural awareness is the deliberate self-examination and in-depth exploration of the biases, stereotypes, prejudices, assumptions, and "isms" that we hold about individuals and groups who are different from ourselves.

Ways to develop cultural sensitivity include all of the following except: A. recognizing that cultural diversity exists. B. respecting the unfamiliar. C. identifying and examining personal beliefs. D. recognizing that all cultures define health in the same way.

D. recognizing that all cultures define health in the same way. All cultures do not define health in the same way. Culturally competent care requires health care providers to be sensitive to patients' heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background.

Mrs. Young has brought her 2-year-old son in for a routine examination. On examination, you elicit a white reflex rather than a red reflex in her son. This indicates: A. congenital glaucoma. B. myosis. C. retinopathy. D. retinoblastoma.

D. retinoblastoma. Initial sign of retinoblastoma is leukocoria, a white reflex (also called a cat's eye reflex) rather than the usual red reflex.

The usual landmark at which the examiner percusses for the lower border of diaphragmatic excursion is the: A. sternum. B. midvertebral line. C. midaxillary line. D. scapular line.

D. scapular line. Measure the diaphragmatic excursion, the movement of the thoracic diaphragm that occurs with inhalation and exhalation. The following steps suggest one approach to measuring the diaphragmatic excursion: Ask the patient to take a deep breath and hold it; percuss along the scapular line until you locate the lower border, the point marked by a change in note from resonance to dullness; and mark the point with a marking pen at the scapular line.

Mrs. Vellok is a 38-year-old patient who presents with a complaint of hearing loss. On examination, pulling Mrs. Vellok's auricle upward and back facilitates visualization of the tympanic membrane by: A. stretching the tympanic membrane. B. straightening the Eustachian tube. C. preventing the tympanic membrane from vibrating. D. straightening the auditory canal.

D. straightening the auditory canal. Examination of the tympanic membrane with the otoscope requires manipulation of the auricle. Use a firm but gentle grasp to avoid causing discomfort. Tilt the patient's head toward the opposite shoulder and, as the speculum is inserted, pull the patient's auricle upward and back to straighten the auditory canal for the best view.

S1 is a ______________ sound that is heard the loudest at the _____________of the heart. A. diastolic; base B. systolic; base C. diastolic; apex D. systolic; apex

D. systolic; apex S1 marks the beginning of systole. S1 coincides with the rise (upswing) of the carotid pulse. S1, which results from closure of the mitral and tricuspid (atrioventricular [AV]) valves, indicates the beginning of systole. It is best heard toward the apex, where it is usually louder than S2.