HA Exam 3 Practice Questions

Heart and neck vessels: 1) What are the 5 major risk factors for heart disease and stroke? 2) What are the 3 other risk factors mentioned?

1) HTN, smoking, DM, obesity, high cholesterol 2) family history of heart disease, age, physical inactivity

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? Inspection Percussion Auscultation Palpation

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

How many degrees is the normal costal angle?

90 degrees or less

Which of the following cranial nerves is assessed by observing the patient making specific facial movements? A) Cranial Nerve VII B) Cranial nerve XI C) Olfactory nerve D) Acoustic nerve

A) Cranial nerve VII Rationale: -The facial nerve (cranial nerve VII) is assessed by observing the patient making specific facial movements. -Cranial Nerve XI is assessed by having the patient shrug against resistance. -The olfactory nerve is assessed by having a patient close his or her eyes, inhale deeply, and identifying the smell. -The acoustic nerve is assessed by performing the whispered voice test.

When auscultating the anterior part of the chest, specifically the apex of the lungs, it is best to auscultate where with the stethoscope? A) Slightly above the clavicle B) 2nd intercostal space mid-clavicular C) 4th intercostal space mid-clavicular D) 6th intercostal space mid-axillary line

A) Slightly above the clavicle

On auscultation of a patient in respiratory distress, you hear a high-pitched, harsh sound that is monophonic and is present only during inspiration. This is known as: A) Stridor B) Vesicular C) Rales D) Rhonchi

A) Stridor

Normal breath sounds include: a) vesicular sounds b) Rhonchi c) wheezes d) crackles

A) Vesicular sounds Rationale: Vesicular sounds are normal breath sounds heard over the periphery of the lung. Rhonchi, wheezes, and crackles are adventitious sounds.

A nurse is assessing a patient's neck with the patient seated. Which of the following is considered an unexpected finding? A) Jugular vein distention B) Midline trachea C) Lack of bruits in carotid arteries D) Thyroid symmetry bilaterally

A) jugular vein distention

A pleural friction rub is best detected by: a) Observation b) Palpation c) Auscultation d) Percussion

c) Auscultation

Neck rotation on each side should be: A) 120 degrees B) 70 degrees C) 10 degrees D) 45 degrees

B) 70 degrees Rationale: Neck rotation should be 70 degrees on each side. Neck flexion and extension should each be 45 degrees.

What is the purpose of having the patient clench his teeth and smile? A) It tests two-point discrimination. B) It tests CN VII and lets you observe tooth occlusion. C) It tests the abdominal reflexes. D) It tests CN III, IV, and VI.

B) It tests CN VII and lets you observe tooth occlusion Rationale: -Having the patient clench the teeth and smile tests CN VII and lets you observe tooth occlusion. In proper occlusion, the upper and lower molars interdigitate, and the premolars and canines interdigitate. -Touching the skin with one or two sterile needles to determine the distance at which the patient can no longer distinguish two points is how two-point discrimination is tested. -Stroking each abdominal quadrant tests the abdominal reflexes. -Cranial nerves III, IV, and VI are tested by checking extraocular movements.

John Joseph was scheduled for a physical assessment. When percussing the client's chest, the nurse would expect to find which assessment data as a normal sign over his lungs? A) Dullness B) Resonance C) Hyperresonance D) Tympany

B) Resonance Rationale: Normally, when percussing a client's chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lungs.

The nurse should use the diaphragm of the stethoscope to auscultate which of the following? A. Heart murmurs B. Jugular venous hums C. Breath sounds D. Carotid bruits

C) Breath sounds Rationale: The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen. The diaphragm is best for higher-pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds.

You are auscultating a patient's lung sounds. During your assessment, you note there is a low-pitched harsh, grating sound that sounds like a pleural friction rub. However, you're not sure if this is a pleural friction rub or pericardial friction rub. What do you do next to determine the difference? A) Have the patient cough and see if the sound clears B) Assess the posterior lower lobe only C) Have the patient hold their breath and note if the sound is still present D) Place the patient in supine position and reassess for the sound

C) Have the patient hold their breath and note if the sound is still present Rationale: A pleural friction rub can sound similar to a pericardial friction rub. If you are unsure about what you are hearing, have the patient hold their breath which will cause the lungs to stop inflating and deflating. If you still hear the sound, it is possible the patient has a pericardial friction rub rather than pleural friction rub. All the other options are incorrect.

Which symptom found when examining the head would be a cause for concern? A) Symmetrical features at rest B) Even distribution of hair C) Bruits in the temporal arteries D) Symmetrical features with movement

C) bruits in the temporal arteries rationale: -bruits in the temporal arteries may indicate a vascular anomaly in the brain. -symmetrical facial features at rest, even distribution of hair, and symmetrical facial features with movement are expected findings

A female client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it's typically due to: A) A neck tumor B) An electrolyte imbalance C) Dehydration D) Fluid overload

D) Fluid overload Rationale: Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. JVD is a sign of increased central venous pressure (CVP). That's a measurement of the pressure inside the vena cava. CVP indicates how much blood is flowing back into the heart and how well the heart can move that blood into the lungs and the rest of the body.

A 70-year-old woman reports dry mouth. The most frequent cause of this is: a) the aging process b) related to medications she may be taking c) the use of dentures d) related to a diminished sense of smell

b) related to medications she may be taking

Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse? A) Aortic arch B) Pulmonic area C) Tricuspid area D) Mitral area

D) Mitral area Rationale: The mitral area (also known as the left ventricular area or the apical area), the fifth intercostal space (ICS) at the left midclavicular line, is the best area for auscultating the apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area is the second intercostal space to the left of the sternum. The tricuspid area is the fifth ICS to the left of the sternum.

Which statement regarding heart sounds is correct? A) S1 and S2 sound equally loud over the entire cardiac area. B) S1 and S2 sound fainter at the apex. C) S1 and S2 sound fainter at the base. D) S1 is loudest at the apex, and S2 is loudest at the base.

D) S1 is loudest at the apex, and S2 is loudest at the base. Rationale: The S1 sound—the "lub" sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the "dub" sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1. Heart sounds are created from blood flowing through the heart chambers as the cardiac valves open and close during the cardiac cycle. Vibrations of these structures from the blood flow create audible sounds — the more turbulent the blood flow, the more vibrations that get created.

In which arteries are bruits considered normal? A) Carotid arteries B) Temporal arteries C) Aortic artery D) None of the above

D) none of the above Rationale: Presence of a bruit is a sign of arterial obstruction. It is not considered normal at any arterial site.

These breath sounds are found anteriorly and posteriorly throughout the peripheral lung fields: a) high-pitched wheezes b) vesicular c) discontinuous d) bronchial

b) vesicular

the frenulum is the: a) midline fold of tissue that connects the tongue to the floor of the mouth b) anterior border or the oral cavity c) arching roof of the mouth d) free projection hanging down from the middle of the soft palate

a) midline fold of tissue that connects the tongue to the floor of the mouth

It is normal to palpate a few lymph nodes in the neck of a healthy person. What are the characteristics of these nodes? a) Mobile, soft, nontender b) Large, clumped, tender c) Matted, fixed, tender, hard d) Matted, fixed, nontender

a) mobile, soft, contender

True or False: the left lung has 3 lobes: left upper lobe, left middle lobe, and left lower lobe.

False Rationale: the right lung has THREE lobes and the left lung has TWO lobes

Normal cervical nodes are: a) Smaller than 1 cm b) Warm to palpation c) Fixed d) Firm

a) smaller than 1 cm

Cephalhematoma is associated with: a) Subperiosteal hemorrhage b) Increased intracranial pressure c) Down syndrome d) Cerebral palsy

a) subperiosteal hemorrhage

Fill in the blanks. S1 is best heard at the _______ of the heart, whereas S2 is loudest at the ______ of the heart. S1 coincides with the pulse in the _________ and coincides with the ______ wave if the patient is on an ECG monitor.

S1 is best heard at the apex of the heart, whereas S2 is loudest at the base of the heart. S1 coincides with the pulse in the carotid artery and coincides with the R wave if the patient is on an ECG monitor.

True or False: During auscultation, the anterior part of the chest mainly provides an assessment of the upper lobes of the right and left lungs, while the posterior part of the chest provides mainly provides an assessment of the lower lobes of the right and left lungs.

True

Where is the apical impulse located? a) in the 5th intercostal space at the midclavicular line b) in the 3rd intercostal space at the left sternal border c) in the 2nd intercostal space at the left sternal border d) in the 2nd intercostal space at the right sternal border

a) in the 5th intercostal space at the midclavicular line

The chamber of the heart that receives oxygenated blood from the lungs is the: a) left atrium b) right atrium c) left ventricle d) right ventricle

a) left atrium

Pulse oximetry measures: a) Arterial oxygen saturation of hemoglobin b) Venous oxygen saturation of hemoglobin c) Combined saturation of arterial and venous blood d) Carboxyhemoglobin levels

a) Arterial oxygen saturation of hemoglobin

A patient has a barrel-shaped chest, characterized by: a) Equal anteroposterior transverse diameter and ribs being horizontal b) Anteroposterior transverse diameter of 1:2 and an elliptic shape c) Anteroposterior transverse diameter of 2 : 1 and ribs being elevated d) Anteroposterior transverse diameter of 3 : 7 and ribs sloping back

a) Equal anteroposterior transverse diameter and ribs being horizontal

When auscultating the heart, your first step is to: a) Identify S1 and S2. b) Listen for S3 and S4. c) Listen for murmurs d) Identify all four sounds on the first round.

a) Identify S1 and S2.

You auscultate a patient to rule out a pericardial friction rub. Which assessment technique is most appropriate? a) Listen with the diaphragm, patient sitting up and leaning forward, breath held in expiration. b) Listen using the bell with the patient leaning forward. c) Listen at the base during normal respiration. d) Listen with the diaphragm, patient turned to the left side.

a) Listen with the diaphragm, patient sitting up and leaning forward, breath held in expiration.

When assessing the tongue, you should: a) Palpate the U-shaped area under the tongue. b) Check tongue color for cyanosis. c) Use a tongue blade to elevate the tongue while placing a finger under the jaw. d) Ask the person to say "ahhh" and note a rise in the midline.

a) Palpate the U-shaped area under the tongue.

Which of the following assessments best confirms symmetric chest expansion? a) Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pincha small fold of skin between the thumbs b) Inspection of the shape and configuration of the chest wall c) Placing the palmar surface of the fingers of one hand against the chest and having the person repeat the words "ninety-nine" d) Percussion of the posterior chest

a) Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pincha small fold of skin between the thumbs

Which description would differentiate a split S2 from S3? a) S3 is lower pitched and is heard at the apex. b) S2 is heard at the left lower sternal border. c) The timing of S2 varies with respirations. d) S3 is heard at the base; the timing varies with respirations.

a) S3 is lower pitched and is heard at the apex.

A nasal polyp is distinguished from the nasal turbinates by 3 of the following. Which reason is FALSE? a) The polyp is highly vascular b) The polyp is movable c) The polyp is pale gray in color d) The polyp is nontender.

a) The polyp is highly vascular

You are assessing an African-American patient and note a flat, 3-cm, nontender, grayish-white lesion on the left buccal mucosa. Which of the following is most likely? a) This lesion is leukoedema and is common in darkly pigmented persons. b) This is the result of hyperpigmentation and is normal. c) This is torus palatinus and would normally only be found in smokers. d) This type of lesion is indicative of cancer and should be tested immediately.

a) This lesion is leukoedema and is common in darkly pigmented persons.

The function of the nasal turbinates is to: a) Warm the inhaled air b) Detect odors c) Stimulate tear formation d) Lighten the weight of the skull bones.

a) Warm the inhaled air

Which of the following indicates normal respiratory function? a) symmetrical chest expansion b) nasal flaring c) use of accessory muscles d) lip pursing

a) symmetrical chest expansion Rationale: -Symmetrical chest expansion is a sign of normal respiratory function. -Nasal flaring is not a normal finding and may be a sign of respiratory distress. -Use of accessory muscles is not a normal finding and may be a sign of respiratory distress. -Lip pursing is not a normal finding and is often taught to COPD patients to control shortness of breath.

The manubriosternal angle is: a) the articulation of the manubrium and the body of the sternum b) a hollow, U-shaped depression just above the sternum c) also known as the breastbone d) a term synonymous with costochondral junction

a) the articulation of the manubrium and the body of the sternum

Which is true regarding cluster headaches? a) They may be precipitated by alcohol and daytime napping. b) Their usual occurrence is two per month, each lasting 1 to 3 days. c) They are characterized as throbbing. d) They tend to be supraorbital, retro-orbital, or frontotemporal.

a) they may be precipitated by alcohol and daytime napping

The largest salivary gland is located: a) within the cheeks in front of the ear b) beneath the mandible at the angle of the jaw c) within the floor of the mouth under the tongue d) at the base of the tongue

a) within the cheeks in front of the ear

The examiner is palpating the apical impulse. Which is a normal-sized impulse? a) Less than 1 cm b) Approximately 1 × 2 cm c) 3 cm d) Varies depending on the size of the person

b) Approximately 1 × 2 cm

During an inspection of a patient's nares, a deviated septum is noted. What should you do next? a) Request a consultation with an ear, nose, and throat specialist. b) Document the deviation in the medical record in case the person needs to be suctioned. c) Teach the person what to do if a nosebleed should occur. d) Explore further because polyps frequently accompany a deviated septum.

b) Document the deviation in the medical record in case the person needs to be suctioned.

Atrial systole occurs: a) During ventricular systole b) During ventricular diastole c) Concurrently with ventricular systole d) Independently of ventricular function

b) During ventricular diastole

You are auscultating breath sounds on a patient. Which of the following best describes how to proceed? a) Hold the bell of the stethoscope against the chest wall; listen to the entire right field and then the entire left field. b) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons. c) Listen from the apices to the bases of each lung field using the bell of the stethoscope. d) Select the bell or diaphragm depending on the quality of sounds heard; listen for one respiration in each location, moving from side to side.

b) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons.

When assessing the carotid artery, the nurse should palpate: a) Bilaterally at the same time while standing behind the patient b) Medial to the sternomastoid muscle, one side at a time c) For a bruit while asking the patient to hold his or her breath briefly d) For unilateral distention while turning the patient's head to one side

b) Medial to the sternomastoid muscle, one side at a time

Select the best description of bronchovesicular breath sounds. a) High-pitched, of longer duration on inspiration than expiration b) Moderate-pitched, inspiration equal to expiration c) Low-pitched, inspiration greater than expiration d) Rustling sound, like the wind in the trees

b) Moderate-pitched, inspiration equal to expiration

You assess a patient who reports a cough. The characteristic timing of the cough of chronic bronchitis is described as: a) Continuous throughout the day b) Productive cough for at least 3 months of the year for 2 consecutive years c) Occurring in the afternoon or evening because of exposure to irritants at work d) Occurring in the early morning

b) Productive cough for at least 3 months of the year for 2 consecutive years

You will hear a split S2 most clearly in which area? a) Apical b) Pulmonic c) Tricuspid d) Aortic

b) Pulmonic

Select the best description of the tricuspid valve. a) Left semilunar valve b) Right atrioventricular valve c) Left atrioventricular valve d) Right semilunar valve

b) Right atrioventricular valve

To use the technique of egophony, ask the patient to: a) Take several deep breaths and then hold for 5 seconds. b) Say "eeeeee" each time the stethoscope is moved. c) Repeat the phrase "ninety-nine" each time the stethoscope is moved. d) Whisper a phrase as auscultation is performed.

b) Say "eeeeee" each time the stethoscope is moved.

The nurse auscultates the pulmonic valve area in which region? a) Second right interspace b) Second left interspace c) Left lower sternal border d) Fifth interspace, left midclavicular line

b) Second left interspace

The isthmus of the thyroid gland lies just below the: a) Mandible b) Cricoid cartilage c) Hyoid cartilage d) Thyroid cartilage.

b) cricoid cartilage

A pulse with an amplitude of 3+ would be considered: a) irregular, with 3 premature beats b) increased, full c) normal d) weak

b) increased, full

A nurse is assessing a patient's neck. Which of the following is considered an expected finding? a) jugular vein distention b) midline trachea c) carotid artery prominence d) thyroid enlargement

b) midline trachea

select the correct description of the left lung: a) narrower than the right lung with 3 lobes b) narrower than the right lung with 2 lobes c) wider than the right lung with 3 lobes d) shorter than the right lung with 3 lobes

b) narrower than the right lung with 2 lobes

These type of breath sounds are found at the site of the bronchi and are located anteriorly at the 1st and 2nd intercostal space & posteriorly in between the scapulae: a) crackles b) wheezes c) bronchovesicular d) bronchial

c) Bronchovesicular

On examining a patient's nails, you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with: a) Acute respiratory distress syndrome b) Normal findings for the nails c) Congenital heart disease and COPD d) Atelectasis

c) Congenital heart disease and COPD

You are assessing a 75-year-old patient's oral cavity. Which of the following would most likely be present? a) Hypertrophy of the gums b) An increased production of saliva c) Decreased ability to identify odors d) Finer and less prominent nasal hair

c) Decreased ability to identify odors

What is the most common site of nose bleeds? a) The turbinates b) the columellae c) Kiesselbach plexus d) the meatus

c) Kiesselbach plexus

When examining for tactile fremitus, it is important to: a) Ask the patient to breathe quickly. b) Ask the patient to cough c) Palpate the chest symmetrically. d) Use the bell of the stethoscope.

c) Palpate the chest symmetrically.

Absence of diaphragmatic excursion occurs with: a) Asthma b) An unusually thick chest wall c) Pleural effusion or atelectasis of the lower lobes d) Age-related changes in the chest wall

c) Pleural effusion or atelectasis of the lower lobes

The function of the pulmonic valve is to: a) Divide the left atrium and left ventricle b) Guard the opening between the right atrium and right ventricle c) Protect the orifice between the right ventricle and the pulmonary artery d) Guard the entrance to the aorta from the left ventricle

c) Protect the orifice between the right ventricle and the pulmonary artery

A murmur is heard after S1 and before S2. This murmur would be classified as: a) Diastolic (possibly benign) b) Diastolic (always pathologic) c) Systolic (possibly benign) d) Systolic (always pathologic)

c) Systolic (possibly benign)

The precordium is: a) A synonym for the mediastinum b) The area on the chest where the apical impulse is felt c) The area on the anterior chest overlying the heart and great vessels d) A synonym for the area where the superior and inferior venae cavae return unoxygenated venous blood to the right side of the heart

c) The area on the anterior chest overlying the heart and great vessels

The stethoscope bell should be pressed lightly against the skin so that: a) Chest hair doesn't simulate crackles. b) High-pitched sounds can be heard better. c) The bell does not act as a diaphragm. d) The bell does not interfere with amplification of heart sounds.

c) The bell does not act as a diaphragm.

The examiner notes small, round, white, shiny papules on the hard palate and gums of a 2-month-old infant. What is the significance of this finding? a) These are aphthous areas or ulcers that are the result of sucking. b) Teeth buds are beginning to appear c) This is a normal finding called Epstein pearls. d) It indicates the presence of a monilial infection.

c) This is a normal finding called Epstein pearls.

The tonsils are graded as 3+. The tonsils would be: a) Visible. b) Halfway between the tonsillar pillars and uvula. c) Touching the uvula. d) Touching each other.

c) Touching the uvula.

Auscultatory sites of the heart include: a) systolic and diastolic murmurs b) bruits and thrills c) aortic, pulmonic, tricuspid, and mitral valves d) extra heart sounds and splitting

c) aortic, pulmonic, tricuspid, and mitral valves Rationale: -Aortic, pulmonic, tricuspid, and mitral areas are normal auscultatory sites of the heart. -Systolic and diastolic murmurs are not auscultatory sites of the heart. Murmurs are long sounds often caused by the backflow of blood. -Bruits and thrills are not auscultatory sites of the heart. A bruit can be a sign of turbulent blood flow, and thrills are fine, rushing vibrations. -Extra heart sounds and splitting are not auscultatory sites of the heart. Extra heart sounds can include ejection clicks and pericardial friction rubs.

Which lymph nodes are located in the depression above and posterior to the medial condyle of the humerus? a) axillary lymph nodes b) inguinal lymph nodes c) epitrochlear lymph nodes d) parotid lymph nodes

c) epitrochlear lymph nodes rationale: -Epitrochlear lymph nodes are found in the forearms. -Axillary lymph nodes are found in the arms, in the axillary region. -Inguinal lymph nodes are found in the inguinal region near the medial thigh. -Parotid lymph nodes are found near the mandible.

Identify the blood vessel that runs diagonally across the sternomastoid muscle. a) Temporal artery b) Carotid artery c) External jugular vein d) Internal jugular vein

c) external jugular vein

On examination, the infant's fontanels should feel: a) Tense or bulging b) Depressed or sunken c) Firm, slightly concave, and well defined d) Pulsating

c) firm, slightly concave, and well defined

While assessing a patient's lung sounds you note bronchial breath sounds in the peripheral lung fields. What could this finding represent? a) this is a normal finding b) pulmonary emboli c) lung consolidation like with pneumonia d) pleuritis

c) lung consolidation like with pneumonia Rationale: Bronhical breath sounds should only be heard in the trachael area. It is ABNORMAL to hear them in the perpherial lung fields. If this happens, it could represent lung consolidation like with pnemonia.

A throbbing, unilateral pain associated with nausea, vomiting, and photophobia is characteristic of: a) Cluster headache b) Subarachnoid hemorrhage c) Migraine headache d) Tension headache

c) migraine headache

Select all of the following that are considered discontinuous breath sounds? a) high-pitched wheeze b) stridor c) pleural friction rub d) fine crackles e) low-pitched wheeze f) coarse crackles

c) pleural friction rub d) fine crackles f) coarse crackles Rationale: The other options are CONTINUOUS breath sounds

When palpating the carotid arteries: a) palpate one artery at a time b) feel for thrills c) use the thumb to palpate d) Both A and B

d) Both A and B Rationale: -Palpating one artery at a time and feeling for thrills are part of a complete assessment of the carotid arteries. -Palpating one carotid artery at a time is part of a complete assessment of the carotid arteries. -One artery is palpated at a time to avoid occlusion of blood flow in the carotid arteries. -Palpation for the presence of thrills is part of a complete assessment of the carotid arteries. -Palpation is performed with the index and middle fingers.

The second heart sound is the result of: a) Opening of the mitral and tricuspid valves b) Closing of the mitral and tricuspid valves c) Opening of the aortic and pulmonic valves d) Closing of the aortic and pulmonic valves

d) Closing of the aortic and pulmonic valves

Oral malignancies are most likely to develop: a) On the soft palate b) On the tongue c) In the buccal cheek mucosa d) In the mucosal "gutter" under the tongue

d) In the mucosal "gutter" under the tongue

After examining a patient, you make the following notation: increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with: a) Bronchitis b) Asthma c) Pleural effusion d) Lobar pneumonia

d) Lobar pneumonia

The examiner is has estimated the jugular venous pressure. Identify the finding that is abnormal. a) Patient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle b) Patient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal angle c) Patient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal angle d) Patient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle

d) Patient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle

On auscultating a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient reports pain with breathing. These findings are consistent with: a) Fine crackles b) Wheezes c) Atelectatic crackles d) Pleural friction rub

d) Pleural friction rub

Which of the following findings during a cardiac assessment of an adult patient are considered normal? a) ejection or systolic clicks b) pericardial friction rubs c) murmurs d) S1 and S2 sounds

d) S1 and S2 sounds Rationale: -S1 and S2 sounds are normal findings in a cardiac assessment. S1 and S2 sounds are heart sounds that always occur and are the most distinct. -Ejection and systolic clicks are not normal findings in a cardiac assessment. Ejection clicks result from faulty opening of the semilunar valves. -Pericardial friction rubs are not normal findings in a cardiac assessment. These are extra heart sounds. -Murmurs are not normal findings in a cardiac assessment. They are relatively long sounds caused by a backward flow of blood.

Bronchial breath sounds canoe auscultated where? a) peripheral lung fields b) sternal area c) mid-scapulae area d) tracheal area

d) Tracheal area

The opening of an adult's parotid gland (Stensen's duct) is opposite to: a) Lower 2nd molar b) Lower incisors c) Upper incisors d) Upper 2nd molar

d) Upper 2nd molar

Providing resistance while the patient shrugs his or her shoulders is a test of which cranial nerve? a) II b) V c) IX d) XI

d) XI

The S1 heart sound: a) is louder at the apex of the heart b) results from closure of the mitral and tricuspid valves c) marks the start of systole d) all of the above

d) all of the above

what information should be included when entering documentation of an enlarged lymph node? a) location, size, and shape b) consistency and tenderness c) discreteness and movability d) all of the above

d) all of the above

When auscultating the lungs, it is important to: a) compare each side bilaterally b) note abnormal sounds c) ask the patient to take slow, deep breaths d) all of the above

d) all of the above Rationale: -All three of the answers are important considerations during auscultation of the lungs. -Comparing each side of the lungs bilaterally during auscultation will allow the nurse to assess whether there is decreased aeration in any of the lung fields. -Noting abnormal sounds during auscultation and documenting where the abnormal sounds are heard is part of a complete assessment of the lungs. -Asking the patient to take slow, deep breaths will assist in thorough auscultation of all lung fields and help keep the patient from hyperventilating.

when palpating the thorax, which of the following would be abnormal finding? a) tenderness b) pulsations c) masses d) all of the above

d) all of the above Rationale: All three of the answers are considered abnormal findings. Tenderness, pulsations, and masses are not a normal finding when palpating the thorax.

When percussing the thorax, which of the following would be a normal finding? a) dullness over the lung fields b) resonance over the lung fields c) dullness over the ribs, heart, and diaphragm d) Both B and C

d) both B and C Rationale: -Both B and C are normal findings. -Dullness over the lung fields during percussion is not a normal finding. -Resonance over the lung fields during percussion is a normal finding. -Dullness over the ribs, heart, and diaphragm during percussion is a normal finding.

When assessing lymph nodes, it is important to do which of the following? a) compare lymph nodes bilaterally b) use the thumbs to palpate c) provide privacy for the patient d) both comparing the lymph nodes bilaterally and providing privacy for the patient

d) both comparing the lymph nodes bilaterally and providing privacy for the patient rationale: -Both comparing the lymph nodes bilaterally and providing privacy for the patient are important for lymph node assessment. -Comparison to determine abnormality on one or both sides is important for lymph node assessment. -Lymph nodes are palpated using the pads of the second and third fingers. Providing patient privacy is an important part of physical assessment.

Which sinuses can you assess through examination? a) Ethmoid and sphenoid b) frontal and ethmoid c) maxillary and sphenoid d) frontal and maxillary

d) frontal and maxillary

If the thyroid gland were enlarged bilaterally, which maneuver would be appropriate for you to assess? a) Check for deviation of the trachea. b) Listen for a bruit over the carotid arteries. c) Listen for a murmur over the aortic area. d) Listen for a bruit over the thyroid lobes.

d) listen for a bruit over the thyroid lobes

Which facial bones articulate at a joint instead of a suture? a) Zygomatic b) Maxilla c) Nasal d) Mandible

d) mandible

Which is least likely to indicate a possible malignancy? a) History of radiation therapy to the head, neck, or upper chest b) History of using chewing tobacco c) History of large alcohol consumption d) Marked tenderness

d) marked tenderness

While reviewing a medical record, a notation of 4+ edema of the right leg is noted. The best description of this type of edema is: a) mild pitting, no perceptible swelling of the leg. b) moderate pitting, indentation subsides rapidly. c) deep pitting, leg looks swollen. d) very deep pitting, indentation lasts a long time.

d) very deep pitting, indentation lasts a long time.

True or False: Low-pitched wheezes are polyphonic sounds that can be cleared when coughing.

false Rationale: Low-pitched wheezes are MONOPHONIC (have one sound quality to them) that are not usually cleared by coughing.