Health Assessment 3202 Exam 2

Shining a light on the bridge of the nose tests

Corneal light reflex

A client diagnosed with Sjogren syndrome should be given which instructions?

Eye drops and sucking on hard candy may used to relieve dryness. Explanation: Sjogren syndrome is a chronic inflammatory disorder characterized by decreased lacrimal and salivary gland secretion. Eye drops and hard candy can provide relief from dryness. Sjogren syndrome does not affect blood pressure. Sjogren syndrome is not contagious or sexually transmitted. Taking mucus thinning medication does not provide relief but could actually lead to additional dryness.

A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

Hyphema Explanation: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye.

When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?

Optic disc Explanation: The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision.

Tonsils greater than 1+ are considered

abnormal

Having the client read letters on a wall chart tests for

central and distance vision.

The transmission of sound waves through the external ear and the middle ear is known as

conductive hearing. Explanation: Conductive hearing is sound waves transmitted by the external and middle ear.

Presbyopia

impaired vision as a result of aging

Drainage from the ears occurs with

otalgia

hordeolum

sty; an acute infection of the lower eyelash

Snellen test

test for distant vision (far)

Which question asked by the nurse is assessing problems with tinnitus?

"Do you experience buzzing in your ears?" Explanation: Problems with balance occur with vertigo.

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?

4mm Pupils are normally equal in size and range from 3 to 5mm large (>5 mm) small (<3 mm)

In which client would the nurse identify receding gums as an expected assessment finding?

A 77-year-old man who describes himself as being healthy Explanation: Receding gums are abnormal in younger clients; in older clients, the teeth may appear longer because of age-related gingival recession, which is common.

An increased risk of falls is dangerous for any client. What client would be at an increased risk of falls?

A client with vertigo. Explanation: Vertigo is defined as the misperception or illusion of motion either of the person or the surroundings. A client suffering from vertigo will be at an increased risk of falls.

The nurse assesses the frontal sinus where?

Above the eyes Explanation: The frontal sinuses are located above the eyes. The maxillary sinuses are located above the jaw.

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom?

Acute bacterial rhinosinusitis Explanation: Frontal sinuses are tender to palpation in clients with acute bacterial rhinosinusitis. This finding would not occur with an eye infection, oropharyngitis, or acute otitis media.

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

Ask the client to remove the glasses before testing. Explanation: When testing distant visual acuity, the nurse should have the client remove the reading glasses, because they blur distant vision. The client would wear his or her glasses during the test if they were not reading glasses. The nurse would still test the client's distant visual acuity. The E chart would be appropriate if the client could not read or has a handicap that prevents verbal communication.

A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12 Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B12 or niacin.

A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, "Do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem?

Cataracts Explanation: Sun exposure is a risk factor for cataracts but is not noted to influence the development of presbyopia, nystagmus, or glaucoma

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstructive pulmonary disease Explanation: An increase in the ratio of anteroposterior to transverse diameter is seen in clients with chronic obstructive pulmonary disease. This occurs because of air trapped in the airways that causes hyperinflation and overdistention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.

What is vital in maintaining vision and a healthy outlook for clients?

Health education Explanation: Nursing education is vital in maintaining vision and a healthy outlook for clients.

A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The mother states no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

Inspect the nostrils with an otoscope Explanation: Because the drainage is unilateral, the most likely cause is a foreign body obstruction. The nurse should inspect the nostrils for patency and the presence of a foreign body. It is not a normal finding in children to have unilateral foul smelling drainage from the nose. This child will not need an antibiotic, so the nurse does not need to assess for allergies to medication. Blowing the nose may or may not dislodge the object and may cause further trauma to the nare.

A hospitalized client who suffered a recent stroke hasn't started a diet yet and has referrals in to speech therapy, occupational therapy, and physical therapy. What is the nurse's best action at mealtime?

Keep the client NPO until speech therapy has seen client. Explanation: The client should remain NPO until evaluated by speech therapy. Occupational therapists do not specialize in swallowing assessments. Physical therapy does not need to be cancelled and should be continued. The nurse, not the nursing assistant, is responsible for assessment

While interviewing a client who complains of earache, the nurse asks, "Is there anything that makes it better or worse?" The client replies, "It hurts much worse when I wiggle my ear." Which of the following conditions should the nurse most suspect?

Otitis externa Explanation: Pain caused by "swimmer's ear," or otitis externa, differs from pain felt in middle-ear infections. If you can wiggle the outer ear without pain, the condition is most likely not swimmer's ear. Earache (otalgia) can also occur with ear infections, cerumen blockage, sinus infections, or teeth and gum problems.

The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which finding would the nurse interpret as being normal?

Pinkish, spongy soft palate Explanation: The soft palate is expected to be pinkish, soft, spongy, and movable.

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity. Explanation: OD = right eye OS = left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less.

Upon inspection of a Native American client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding?

This is often a normal finding in the Native American population. Explanation: A bifid or split uvula is a common finding in the Native American population. Clients with a bifid uvula may have a submucous cleft palate.

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?

Thrush Explanation: Thick, white plaques that are partially adherent to the oral mucosa are associated with thrush. HIV and AIDS are predisposing factors. People with HIV and AIDS are also prone to Kaposi's sarcoma, but these lesions are typically deep purple. Diphtheria causes a dull redness in the throat, and a torus palatinus is a bony growth in the hard palate.

It has become apparent that there is not a lifetime immunity to pertussis for those who received the childhood DPT vaccine.

True pg 337

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment Explanation: The nurse should assess with each client the use of safety equipment when playing sports. Proper eye protection can prevent many sports-related eye injuries. All options are points for client teaching for this client; however, the most important opportunity involves the use of safety equipment.

The submandibular glands open under the tongue through openings called

Wharton ducts. Explanation: The submandibular glands, located in the lower jaw, open under the tongue on either side of the frenulum through openings called Wharton's ducts.

Moving the eyes in the direction of a moving finger tests for

extraocular vision

chalazion

infected meibomian gland in the lower lid.

When inspecting a client's teeth, the nurse notes gingival hyperplasia. What should the nurse assess to determine the cause for this finding?

medications Explanation: Gingival hyperplasia is an overgrown of the gum tissue. A common cause for this disorder is the medication phenytoin (Dilantin). Gingival hyperplasia is not associated with tobacco use, oral fluid intake, or respiratory illnesses.

The optic nerves from each eyeball cross at the

optic chiasma. Explanation: At the point where the optic nerves from each eyeball cross—the optic chiasma—the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.

Straight movements of the eye are controlled by the

rectus muscles. Explanation: The extraocular muscles are the six muscles attached to the outer surface of each eyeball. These muscles control six different directions of eye movement. Four rectus muscles are responsible for straight movement, and two oblique muscles are responsible for diagonal movement.

The nurse is assessing a client with chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize?

"How often do you use over-the-counter nasal sprays?" Explanation: Overuse of nasal sprays may cause nasal irritation, nosebleeds, and rebound swelling. These symptoms are not characteristic of poor nutrition or heavy alcohol use. Acetaminophen does not result in bleeding or chronic nasal congestion.

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. Which of the following should the nurse mention to the client as potential risk factors?

-Ultraviolet light exposure. -Obesity. Explanation: Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Obesity also increases risk of cataracts. Consistent use of sunglasses during exposure and healthy weight management techniques minimize the client's risk.

A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform?

Assess the nasolacrimal sac. Explanation: Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength, such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.

The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform?

Confrontation test Explanation: The confrontation test evaluates peripheral vision. The cover test, corneal light reflex test, and eye position test would be used to evaluate extraocular muscle function.

A client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?

Conjunctivitis Explanation: Redness of the conjunctiva is called conjunctivitis and can be due to n allergic reaction, and viral or bacterial infection. Blepharitis is an infection of the eyelid by the staphylococcus bacteria. A hordeolum is also called a stye and is caused by infection in the lower eyelashes. A chalazion is an infected meibomian gland in the lower lid.

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following?

Consensual response Explanation: When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light in one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict.

A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered, or tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?

Continue with the examination Explanation: Earlobes may be free, attached, or soldered (tightly attached to adjacent skin with no apparent lobe). Most African Americans and Caucasians have free lobes, whereas most Asians have attached or soldered lobes, although any type is possible in all cultural groups. Thus, this finding is normal and does not need to be reported to the physician, followed up on with a question to the client about an ear injury, or recorded and followed up on at a later visit.

A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?

Cyanotic Explanation: Cyanotic lips are seen in cases of cold or hypoxia. The finding of reddish lips supports the diagnosis of carbon monoxide poisoning. Pallor around the lips is a finding in clients with anemia and shock. Swelling of the lips is common in local or systemic allergic reaction.

A 12-year-old boy was brought to the emergency department after being hit in the head with a ball during a baseball game. What assessment finding would suggest to the nurse trauma to the middle ear or inner ear?

Dark red or bluish tympanic membrane Explanation: A blue or dark red tympanic membrane indicates blood behind the eardrum due to trauma. A yellow appearance is suggestive of ear infection, and white spots or streaks are caused by recurrent infections.

What is a characteristic symptom of Graves hyperthyroidism?

Exophthalmos Explanation: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumor and inflammation in the orbit.

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear Explanation: The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. The other options do not accurately describe the function of the eustachian tube.

Which finding should a nurse recognize as a normal when assessing the ears of an elderly client?

High tone frequency loss Explanation: Presbycusis, a gradual hearing loss, is common after the age of 50 years. It begins with a loss of the ability to hear high frequency tones. Cerumen production may increase in older age or become drier and build up as the cilia become more rigid. The pinna looses elasticity in older age. A bulging tympanic membrane is not a normal finding at any age.

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

History of allergies Explanation: Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa, hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis or other infectious processes.

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?

History of allergies Explanation: Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Dysphagia would suggest a problem with the throat. Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa , hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis.

Normal movement of the eye involves what cranial nerves? (Mark all that apply.)

II III IV VI Explanation: As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves: Cranial nerve II, optic nerve, visual acuity, visual fields, fundoscopic examination; cranial nerve III, oculomotor, cardinal fields of gaze, eyelid inspection, pupil reaction (direct/consensual/ accommodation); cranial nerve IV, trochlear, cardinal fields of gaze; and cranial nerve VI, abducens, cardinal fields of gaze. Cranial nerve V, known as the trigeminal nerve, is a nerve responsible for sensation in the face and certain motor functions such as biting and chewing.

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

Narcotic use Explanation: Pinpoint pupils suggest narcotic use or brain damage. Hyphema would suggest recent eye trauma. Dilated and fixed pupils typically result from central nervous system injury, circulatory collapse, or deep anesthesia.

While inspecting the tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following?

Normal tympanic membrane Explanation: The tympanic membrane is normally a pearly gray color with a shiny appearance. White spots would indicate scarring. A yellowish bulging membrane would suggest serous otitis media; a red bulging membrane would suggest acute otitis media.

The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

Notify the healthcare provider about the finding. Explanation: Lymph tissue should not be palpable on the ears. Enlarges lymph nodes indicate pathology or inflammation; and the healthcare provider should be notified. Ear drops are not indicated since the node is on the auricle, not in the canal. An audiogram is indicated for hearing loss.

A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa Explanation: Pain with auricle movement or tragus palpation indicates otitis externa or furuncle.

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

Presbyopia Explanation: Presbyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes.

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?

Red, swollen, with purulent discharge Explanation: The nurse should find red, swollen nasal mucosa with purulent discharge in the client diagnosed with upper respiratory tract infection. Dark pink, moist nasal mucosa which is free of exudate is a normal finding. Pale pink, swollen nasal mucosa with watery exudate and bluish gray, swollen nasal mucosa with watery exudate is found in cases of allergy.

On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?

Right homonymous hemianopsia Explanation: Because the right visual field in both eyes is affected, this is a right homonymous hemianopsia. A bitemporal hemianopsia refers to loss of both lateral visual fields. A right temporal hemianopsia is unilateral, and binasal hemianopsia is the loss of the nasal visual fields bilaterally.

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet. Explanation: The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet.

A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?

Torus palatinus Explanation: Torus palatinus is relatively common and benign but can go unnoticed by clients for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and seen in immunosuppressed clients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive people; these lesions are classically deep purple.

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to

corneal damage. Explanation: Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

esotropia

Asthenopia

eyestrain symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches.

The frontal sinuses are the only ones readily accessible to clinical examination.

false

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?

far, then near Explanation: When testing accommodation, the nurse would ask the client to focus on a distant object such as a finger or pencil and to remain focused on that object as the nurse moves it closer to the eyes.

Hyperopia

farsightedness

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the

frenulum. Explanation: The tongue is a mass of muscle, attached to the hyoid bone and styloid process of the temporal bone. It is connected to the floor of the mouth by a fold of tissue called the frenulum

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

macular degeneration Explanation: Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision.

A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should

tell the client that these often occur with aging. Explanation: Spots or floaters are common among clients with myopia or in clients over age 40. In most cases, they are due to normal physiologic changes in the eye associated with aging and require no intervention.

A negative red glow on transillumination of the sinuses indicates

that a sinus is filled with pus or fluid

Paralysis of cranial nerve X (vagus) often causes

the uvula to deviate to one side and the palate to fail to rise. Enlargement of the tonsils does not cause a bifid uvula.

A CVA may cause asymmetrical or loss of movement of the

uvula

During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which statement would the nurse include in the response?

"Arteries have thicker walls than veins." Explanation: Arteries are blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries via a high-pressure system. Arterial walls are thick and strong and contain elastic fibers for stretching. Veins contain nearly 70% of the body's blood volume.

A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Explanation: Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted clients; no additional follow-up is needed.

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

"Right carotid bruit auscultated" Explanation: Bruits are swooshing sounds similar to the sound of the blood pressure. They result from turbulent blood flow related to atherosclerosis. A bruit is audible when the artery is partially obstructed. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. Neither split sounds nor an S2 is heard over arteries.

The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?

"You have a conductive hearing loss." Explanation: The Rinne test tests for conductive hearing loss. The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds. An audiogram can reveal a nerve related or unilateral hearing loss.

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?

"Your risk for heart disease will drop greatly if you're able to stop smoking." Explanation: Smoking is among the most significant risk factors for heart disease. Screening does not need to be performed on a twice yearly basis. Stress reduction is beneficial, but smoking is a greater risk factor than stress. Dietary fat is a risk factor, but for most clients there is not a need to wholly eliminate red meat from the diet.

Which of the following are the main functions of the cardiovascular system? (Choose all that apply.)

- Deliver oxygen to the tissues - Remove waste products from the tissues - Maintains perfusion to the body tissues.

The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.)

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

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next?

2nd intercostal space left sternal border Explanation: Since the nurse started at the base of the heart, the next location to assess would be the 2nd intercostal space left sternal border. The 3rd left intercostal space would be assessed next and followed by the 4th intercostal space. The 5th left intercostal space midclavicular line would be assessed last.

Where is Erb's point located?

3rd left rib space Explanation: Erb's point is located on the left side of the chest. Walk the fingers one rib space at the left sternal border (approximately 1 inch apart) to locate the 3rd intercostal space (ICS) on the left; this is the third site for auscultation, Erb's point. Walk the fingers to the 4th or 5th ICS for the fourth site, called the tricuspid area. Move the fingers along the 5th ICS to the midclavicular line for the 5th location, the mitral area.

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals Explanation: A tophus is a hard nodule composed of uric acid crystals. A cyst on the ear would present as a fluid-filled sac. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Scarring of the tympanic membrane occurs with repeated ear infections with perforation of the tympanic membrane

A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

A thrill Explanation: Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest, which is not a normal finding.

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?

Accentuated Explanation: An accentuated S2 means that the S2 is louder than the S1. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. A diminished S2 means that the S2 is softer than the S1. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Normal split S2 can be heard over the second or third left intercostal space; it is usually heard best during inspiration and disappears during expiration. Wide split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle, and widens on expiration.

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?

Acute otitis media Explanation: A red, bulging eardrum coupled with distorted, diminished, or absent light reflex is associated with acute otitis media. Repeated ear infections usually cause the formation of white scar tissue. Trauma causes the accumulation of blood behind the eardrum, which appears blue or dark red.

The nurse knows that the vasa vasorum is found where?

Adventitia of the artery Explanation: The outer layer of the artery is the adventitia, connective tissue containing nerve fibers and the vasa vasorum.

A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition?

Ankle-brachial index (ABI) Explanation: The ABI is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Approximately 16% of clients with known peripheral vascular disease also have coronary artery disease.

When reviewing ear assessment, a student nurse would learn that the cone of light should be visible where on the tympanic membrane?

Anterior inferior quadrant Explanation: The healthy tympanic membrane is intact and translucent and allows visualization of the short process of the malleus. The cone of light is visible in the anterior inferior quadrant. The other options do not accurately describe the location of the cone of light.

When a client is obese or has a thick chest wall, what is difficult to palpate?

Apical impulse Explanation: Obesity or a thick chest wall makes palpation of the apical impulse difficult.

Infarct

Area of dead tissue after a lack of blood supply may be caused by decreased cardiac output

During an assessment, the nurse first performs the action shown. After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing?

Arterial insufficiency Explanation: The color change test is to check for arterial insufficiency. With the client supine, the legs are elevated about 30 cm (12 in.) above the level of the heart. Then when have the client sit up and dangle the legs. Color should return to the feet and toes within 10 seconds. The superficial veins of the feet fill within 15 seconds. Return of color taking longer than 10 seconds or persistent dependent rubor indicates arterial insufficiency. This is not a technique to assess lymphedema, the femoral pulse, or intermittent claudication.

A nurse assesses the peripheral vascular system of a client who is in the supine position. What further assessment should the nurse perform if unable to palpate the left popliteal pulse?

Assist the client to the prone position and palpate again. Explanation: If the nurse is unable to palpate the popliteal artery with the client in supine position, the nurse should assist the client to prone position and palpate again. If the nurse is still unable to palpate, a Doppler should be used. The nurse may partially raise the client's leg and place the fingers deep in the bend of the knee when in prone position, not in supine position. The nurse need not assist the client to lateral position and palpate

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Assist the client to walk as soon and as often as possible. Explanation: Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

An older adult client has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the nurse practitioner want to have this client assessed for by a cardiologist?

Atherosclerotic stenotic carotid arteries Explanation: If the carotid artery pulse is diminished unilaterally or bilaterally (often associated with a systolic bruit), the cause may be carotid stenosis from atherosclerosis. These signs would not indicate anything valvular; the client's age would negate the likely existence of a congenital problem.

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. What would the nurse do next?

Auscultate for pulse rate deficit. Explanation: If the nurse detects an irregular rhythm, the nurse needs to auscultate for a pulse rate deficit, which may provide further evidence of atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block. The client also should be referred for further evaluation because irregular rhythms may predispose the client to decreased cardiac output, heart failure, or emboli. It would not be necessary to inspect for a lift or palpate for a thrill. These would most likely have already been completed. Listening for a ventricular gallop would occur later, when the nurse is auscultating for normal and abnormal heart sounds.

When assessing temperature of the skin, which portion of the hand should the examiner use?

Backs of fingers Explanation: The backs of the fingers are thought to be the most temperature sensitive, perhaps because the skin is thinnest there. The nurse may have difficulty detecting subtle differences without using the backs of the fingers.

A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?

Bradycardia Explanation: The proper documentation of this rate is bradycardia, a rate less than 60 beats per minute. The normal adult heart rate is 60 to 100 beats per minute. Tachycardia is a heart rate above 100 beats per minute. This heart rate is decreased, but this is not a proper documentation term.

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

Cardiac cycle Explanation: The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle.

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

Check the insertion site for redness. Explanation: Fever above 100.4 degrees Fahrenheit can indicate a central-line associated bloodstream infection for this client. The nurse should assess the insertion site for redness, edema, or purulent drainage and notify the healthcare provider for further treatment. Depending on the signs of infection that are present at the insertion site, the provider may discontinue the line and culture the tip. Flushing the ports with saline can assist the nurse in checking patency of the lines

Which symptoms would indicate to the nurse the client may be experiencing a cardiac event? Select all that apply.

Chest pain Diaphoresis Dyspnea Fatigue Explanation: Common cardiovascular symptoms include chest pain, dyspnea, diaphoresis and fatigue. Hypotension is not a common cardiovascular symptom.

When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency?

Cigarette smoking Explanation: The use of any form of tobacco significantly increases a person's risk for chronic arterial insufficiency. The risk increases according to the length of time a person smokes and amount of tobacco smoked. Daily exercise would be a measure to reduce a person's risk for vascular disease. Family history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated lipid levels would be important because these disorders tend to be heredity and cause damage to the blood vessels. Alcohol intake is unrelated to the development of chronic arterial insufficiency.

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply.

Cigarette smoking Previous use of hormones High-fat diet Explanation: The risk factors for the development of peripheral vascular disease include smoking, lack of exercise, high stress, moderate to high alcohol intake, previous use of hormonal birth control (females), and a high-fat diet.

A nurse is unable to palpate the apical impulse on a client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?

Client has an increased chest diameter Explanation: The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical pulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Cool foot temperature and ulceration on the client's great toe Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

Cool skin Explanation: A cool extremity may be a sign of arterial insufficiency. The other findings listed are all normal.

A 72-year-old retired teacher comes to the clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes are risk factors for peripheral vascular disease?

Coronary artery disease Explanation: Evidence of coronary artery disease implies that there is most likely disease in other vessels; therefore, this is a risk factor for peripheral vascular disease. Conversely, the presence of peripheral vascular disease is also a risk factor for coronary artery disease and, if present, should accompany reduction of cardiac risk factors.

Conduction System

Electrical impulses from nerves that stimulate contraction and relaxation of heart Originates @ SA Node (pacemaker) and spreads through the atria to the AV node, then travels to bundle of His, then right & left bundle branches, & then through ventricles SA Node--> AV Node --> Bundle of His---> L&R Bundle Branches--->Purkinjie fibers

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?

Extent of tobacco use and exposure Explanation: Tobacco use is one of the most significant risk factors for PAD and would supersede exercise tolerance, prevention of varicose veins, or dysrhythmias.

The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?

Fifth intercostal space, left midclavicular line Explanation: The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line.

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Have the client hold his or her breath; if the rub persists, it is pericardial Explanation: Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Have the client hold his or her breath; if the rub persists, it is pericardial Explanation: Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs.

When assessing a client for possible varicose veins, which of the following would the nurse do?

Have the client stand for the exam Explanation: When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is used to assess the Homans' sign. The ankle-brachial index is used if the client has symptoms of arterial occlusion.

The nurse is assessing a client for varicose veins. Which action, by the nurse is appropriate?

Have the client stand for the exam. Explanation: When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is not part of this assessment. The ankle-brachial index is used if the client has symptoms of arterial occlusion.

A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem?

Heart failure Explanation: Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart causing blood returning to the heart to back up in the organs and dependent areas of the body. Edema is not associated with MI, heart block, or atherosclerosis.

A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, what information would the nurse include?

Hypertension is more prevalent in African Americans than among Caucasians. Explanation: Ethnicity plays a role in developing coronary heart disease. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease thought to be due to more severe hypertension and higher rates of obesity and diabetes in these populations.

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

II Explanation: A grade II murmur is quiet and heard immediately when auscultating the chest. A grade I murmur is very faint, heard only after the listener has "tuned in." A grade III murmur is moderately loud. A grade IV murmur is loud.

During the history a client reports a blockage in the upper portion of the nasal passage. Which of the following would the nurse expect as a prominent symptom?

Inability to smell Explanation: Receptors for cranial nerve I (olfactory) are located in the upper part of the nasal cavity and septum. Blockage would decrease the ability to smell. A decreased ability to taste would be associated with an upper respiratory infection or lesion of the facial nerve. Difficulty hearing or occasional dizziness are associated with ear problems.

The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply.

Increased cardiac output Increased blood pressure Increased heart rate Explanation: When the sympathetic nervous system is stimulated, epinephrine and norepinephrine are released which causes an increased heart rate and cardiac output and increase in the blood pressure.

A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?

Ineffective Tissue Perfusion Explanation: The nurse assesses a decrease in the carotid pulses (1+ is considered weak) and a weak radial pulse is present. The client also has a murmur. These findings allow the nurse to confirm the diagnosis of Ineffective Tissue Perfusion. There are not enough criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective Health Maintenance.

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Inflammation of the pericardial sac Explanation: A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur.

A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral arterial disease. Which of the following is a common symptom that could indicate peripheral arterial disease?

Intermittent claudication Explanation: Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral arterial disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.

Across the lifespan, a nurse knows what characteristic of the female heart is consistently true?

Is normally smaller than the male heart Explanation: The total size of the heart is approximately that of a clenched adult fist. The female heart is normally smaller and weighs less than the male heart across all age groups. The female heart does not consistently beat more slowly than a male heart.

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

It filters harmful substances from the body. Explanation: The lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them to the venous system. The system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced by the immune system.

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

It filters harmful substances from the body. Explanation: The lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them to the venous system. The system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced by the immune system.

A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position?

Leaning forward while in a sitting position Explanation: For best results, the nurse would use the diaphragm of the stethoscope and have the client sit up, lean forward, exhale, and hold his or her breath. The left lateral position may be used to hear an S3 or S4 heart sound or a murmur of mitral stenosis that was not detected in the supine position.

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?

Legs should be elevated for 15 seconds Explanation: When performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test.

Systolic BP

Maximum pressure felt on artery during L ventricular contraction

Variations in the presentation of S1 are due to alterations in which heart valve?

Mitral Explanation: The sound of S1 is produced at the onset of systole, which is the closure of the mitral and tricuspid valves. The variations in the intensity of S1 are due to the position of the mitral valve at the start of systole and can cause the sound to be accentuated, diminished, or variable. The tricuspid valve is involved when there is a split S1, which causes the ventricles to contract at different times. The aortic and pulmonic valve closures produce the sound of S2.

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

Murmur Explanation: Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.

A nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known as which of the following?

Myocardium Explanation: The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The pericardium is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This same type of serous membrane covers the outer surface of the heart and is known as the epicardium. The endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels.

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?

Myopia Explanation: Myopia is nearsightedness, meaning the client can see objects better up close. Asthenopia is eye strain, and symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches. Hyperopia is farsightedness. Presbyopia commonly occurs naturally due to the aging process; therefore it's rare to observe this condition in young adults.

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

Normal finding Explanation: Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Notify the healthcare provider. Explanation: The client is exhibiting signs of venous thromboembolism. The healthcare provider should be notified immediately to prevent further complications. This condition is a national client safety concern for hospitalized clients. Early ambulation could dislodge a possible clot. Prevention of pneumonia is encouraged by turning, coughing, and deep breathing. Signs of a urinary tract infection include pain, increased white blood cells, and fever.

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action?

Observing the eye's reaction when a light is shone into the opposite eye Explanation: The nurse assesses consensual response at the same time as direct response by shining a light obliquely into one eye and observing the pupillary reaction in the opposite eye. This does not involve a comparison between maximum and minimum pupil size, however. Neither eye is covered, and peripheral vision is not relevant to this assessment.

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?

On the client's mastoid process Explanation: For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is placed in the center of the client's forehead or head for the Weber test.

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

Orthopnea Explanation: Orthopnea, which is dyspnea that occurs when lying down and improves when sitting up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following?

Pacemaker Explanation: The sinoatrial node is often called the pacemaker of the heart because it generates impulses that are conducted through the heart. The impulse is conduced across the atria to the AV node, which then relays the impulse to the AV bundle or bundle of His. From here the impulse travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles. All these structures make up the conduction system of the heart.

The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate?

Palpate each artery individually to compare. Explanation: When assessing a client's carotid arteries, the nurse should palpate each artery individually because bilateral palpation could result in reduced cerebral blood flow. Auscultation should be done before palpation because palpation may increase or slow the heart rate, changing the strength of the carotid pulse heard. The nurse should use the bell of the stethoscope to auscultate the arteries and have the client hold the breath for a moment so breath sounds do not conceal any vascular sounds.

A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next?

Palpate the brachial pulse. Explanation: When unable to palpate a peripheral pulse, the pulse area immediately proximal to it should be palpated. In this case, the brachial pulse is indicated. Inability to palpate the client's pulses suggests arterial insufficiency.

A nurse is unable to palpate a client's radial and ulnar pulses. What is the most appropriate nursing action?

Palpate the brachial pulse. Explanation: When unable to palpate a peripheral pulse, the pulse area immediately proximal to it should be palpated. In this case, the brachial pulse is indicated. Inability to palpate the client's pulses suggests arterial insufficiency. The nurse should not abandon this component of assessment. Referral is not always necessary, and further data are needed

While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following?

Pericardial friction rub Explanation: A pericardial friction rub is best heard in the third intercostal space at the left sternal border and is associated with a high-pitched, scratchy sound caused by inflammation of the pericardial sac. A mid-systolic click is heard in middle or late systole over the mitral or apical area. A summation gallop is the simultaneous occurrence of S3 and S4 sounds. An aortic ejection click is heard during early systole at the second right intercostal space and apex.

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?

Peripheral arterial disease Explanation: Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.

An older client is hospitalized with pneumonia. The nurse suspects the client is developing severe sepsis based on which assessment findings? (Select all that apply.)

Platelet count 90,000 Pulse 104 beats/minute PaCO2 30 mmHg Explanation: Initial signs of severe sepsis include: heart rate greater than 90 beats/min; platelet count less than 100,000; temperature less than 36 or greater than 38.3 degrees Celsius; PaCO2 less than 32 mmHg; white blood cells greater than 12,000 or less than 4,000 mm3.

What action should the nurse implement when assessing the ear of an adult client using an otoscope?

Pull the auricle out, up, and back. Explanation: The nurse should pull the auricle out, up, and back to straighten the external auditory canal. This is because the external auditory canal is S-shaped in the adult. The outer part of the canal curves up and back, and the inner part of the canal curves down and forward. The nurse should choose the largest speculum that fits the client's ear. The nurse should hold the speculum in the dominant hand and insert the speculum gently down and forward.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media?

Red, bulging with an absent light reflex Explanation: A client with acute otitis media would have a red, bulging eardrum with absent light reflex. A pearly, translucent membrane with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane with bubbles is seen in serous otitis media. A gray, translucent membrane with retraction is a normal finding in the tympanic membrane.

The direction of blood flow through the heart is best described as?

Right atrium → right ventricle → pulmonary artery → lungs → pulmonary vein → left atrium → left ventricle

Which of the following tests use a tuning fork between two positions to assess hearing?

Rinne Explanation: In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air conduction of sound and bone conduction of sound. The whisper test involves covering the untested ear and, whispering from a distance of 1 or 2 feet from the unoccluded ear, and the ability of the client to repeat what was whispered. The watch tick test relies on the ability of the client to perceive the high-pitched sound made by a watch held at the client's auricle. The Weber's test uses bone conduction to test lateralization of sound.

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

S1 Explanation: The S1 heart sound is associated with systole, while the S2, S3, and S4 heart sounds are associated with diastole.

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?

S2 Explanation: Diastolic murmurs occur during filling, from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed. Preload is an indicator of how much blood will be forwarded to and ejected from the ventricles. The heart has to pump against the high blood pressures in the arteries and arterioles. This pressure in the great vessels is termed afterload. Preload and afterload are not heart sounds but volume and pressure indicators.

P wave

SA Node depolarization of the atria

Which component of the conduction system referred to as the pacemaker of the heart?

SA node Sinoatrial

Which of the following is a symptom of the eye?

Scotomas Explanation: Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye.

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?

Shortness of breath Explanation: Clients with heart failure may be short of breath from fluid accumulation in the pulmonary bed. Onset may be sudden with acute or chronic pulmonary edema. It is important to assess how much activity brings on dyspnea, such as rest, walking on a flat surface, or climbing. The other options listed are distracters to the question.

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses?

Sitting with the head erect and at the eye level of the nurse Explanation: The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner. Tilting the head backwards and a semi-recumbent position with the chin lifted will make it more difficult to visualize the mouth and nose. The prone position will make transillumination and palpation of the sinuses more difficult for the examiner

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Smoking increases the heart's workload and contributes to atherosclerosis. Explanation: Smoking increases cardiac workload and contributes to hypertension, plaque build-up, and blood clots. It does not directly affect contractility or cardiac conduction, and it is not a component of metabolic syndrome.

A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honor student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms?

Spontaneous pneumothorax Explanation: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds; on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan syndrome.

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time. Explanation: The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

The client's toe is receiving an inadequate supply of blood. Explanation: Arterial ulcers are frequently circular, painful, and deep. Venous ulcers, in contrast, are typically superficial with an irregular border. Disruptions in lymphatic function or osmosis would not result in a wound of this type.

carotid artery

The major artery that supplies blood to the head and brain. It is located in the groove between the trachea & sternomastoid muscle

Where are the heart and great vessels located in the human body?

The mediastinum, between the lungs above the diaphragm Explanation: The heart and great vessels are located in the mediastinum between the lungs and above the diaphragm from the center to the left of the thorax.

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. Explanation: In the Rinne test, the nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear.

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

The right lung has three lobes, while the left lung has two lobes. Explanation: The right lung is made up of three lobes, whereas the left lung contains only two lobes. The sizes of the lungs are not identical but do not differ by one-third. The lower lobes of both lungs are primarily located toward the posterior surface of the chest wall.

A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which information would the nurse describe?

The size and shape of children's eustachian tubes makes them vulnerable. Explanation: The fact that children are more susceptible than adults to otitis media is due mostly to the shorter, straighter, narrower eustachian tubes of children. Otitis media in children is not normally associated with putting things in their ears, immature immune systems, or poor hygiene.

A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear Explanation: Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?

There is loss of involuntary respiratory control. Explanation: The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts.

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light. Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if either or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation and occurs when focus of vision is moved from a far object to a close object. Light reflection appearing at different spots on both eyes is an abnormal result of the corneal light reflex test, not of the consensual pupillary reaction to light test.

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?

Thin, shiny, atrophic skin Explanation: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.

The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.

True

The nurse determines that a client's edema of the lower extremities is most likely due to lymphedema based on which of the following?

Unilateral edema Explanation: Edema associated with lymphedema is usually nonpitting, unilateral, and without any skin ulceration or pigmentation. Edema associated with chronic venous insufficiency is usually pitting, and with skin ulceration and pigmentation.

Which of the following veins drain into the superior vena cava? (Mark all that apply.)

Upper torso Head Upper extremities Explanation: The veins of the upper extremities, upper torso, head, and neck drain into the superior vena cava and then the right atrium. The lower extremities and lower torso drain into the inferior vena cava. Reference:

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking?

Use a Snellen E chart to perform the examination Explanation: If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze test eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision.

The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?

Venous insufficiency Explanation: A rusty or brownish pigmentation around the ankles indicates venous insufficiency. This assessment finding is not suggestive of Raynaud's, CAD, or edema.

The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?

Venous insufficiency Explanation: A rusty or brownish pigmentation around the ankles indicates venous insufficiency. This assessment finding is not suggestive of Raynaud's, CAD, or edema.

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral?

Venous insufficiency Explanation: Brown discoloration around the ankles occurs with chronic venous stasis resulting from hemosiderin deposits, which are byproducts of red blood cell degradation or iron deposits left behind from the process. There is no evidence of ulceration. Arterial occlusion would be associated with weak or absent pulses. Dependent edema is edema that results from the legs being in a dependent or down position. A brown pigmentation would not be present with dependent edema.

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Venous insufficiency Explanation: Brown discoloration around the ankles occurs with chronic venous stasis resulting from hemosiderin deposits, which are byproducts of red blood cell degradation or iron deposits left behind from the process. There is no evidence of ulceration. Arterial occlusion would be associated with weak or absent pulses. Dependent edema is edema that results from the legs being in a dependent or down position. A brown pigmentation would not be present with dependent edema.

Cardiac Output

Volume of blood pumped from a heart per minute Adults pump 4-6L of blood throughout the body/minute

The nurse reads the previous shift's assessment documentation and notes local swelling, redness, and warmth. The oncoming nurse palpates a subcutaneous cord and suspects

a superficial thrombophlebitis Explanation: Superficial vein thrombophlebitis is marked by redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking. Swelling and inflammation are often noted.

The functional reflex that allows the eyes to focus on near objects is termed

accommodation. Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.

Crackles and wheezing are

adventitious breath sounds

Nasal mucosa that is pale pink and swollen suggest

allergies

The school nurse hears an extra heart sound on a 16-year-old male athlete. The nurse believes this is because

an extra heart sound in a child or young adult is usually considered a physiological S3 and is considered normal

Blepharitis

an infection of the eyelid by the staphylococcus bacteria.

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's

apex of the heart. Explanation: S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS).

The bicuspid, or mitral, valve is located

between the left atrium and the left ventricle.

Pulse Pressure

difference between systolic and diastolic pressure

jugular vein

empty unoxygenated blood directly into the superior vena cava

The nurse is planning to assess a client's near vision. Which technique should be used?

have the client read newspaper print held 14 inches from the eyes Explanation: Near vision is tested by asking the client to read newspaper print held 14 inches from the eyes.

endocardium

inner lining of the heart/endothelial tissue that lines the inner surface of the heart chambers & valves

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

left midclavicular line at the fifth intercostal space Explanation: The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left midclavicular line when the client is placed in a sitting position.

internal jugular vein

lies deep and medial to sternomastoid muscle

Myocardium

muscular wall of the heart, it does the pumping

The anterior chest area that overlies the heart and great vessels is called the

precordium

Mean Arterial Pressure (MAP)

pressure forcing blood into tissues

Diastolic BP

resting pressure that blood exerts constantly between each contraction

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

right cervical node Explanation: The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct.

S1

the first heart sound, heard when the AV (mitral and tricuspid) valves close

blood pressure

the force of blood pushing against the walls of the vessel wall

S2

the second heart sound, heard when the semilunar (aortic and pulmonic) valves close

Stroke volume

the volume of blood pumped from the heart with each per beat

Pericardium

tough, fibrous layer that surrounds & protects the heart

external jugular vein

vein is more superficial, lies lateral to sternomastoid muscle, above clavicle

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

venous insufficiency Explanation: Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.

QRS wave

ventricular depolarization (contraction)

T wave

ventricular repolarization

A client appears in the clinic with a cough that began 24 hours prior to coming to this visit. The nurse evaluates the client based on the most common cause of an acute cough, which is

viral respiratory infection