Health Assessment Exam 2 Review

During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk for skin cancer? a. Use a tanning booth instead of sunning outside if a tan is desired. b. Wear protective clothing while in the sun. c. Perform self-examination of skin monthly. d. Use sunscreen with a sun protection except on overcast days

. ANS: B Feedback A Avoiding tanning and sunning are part of primary prevention. B Wearing protective clothing while in the sun provides primary prevention for skin cancer. C Performing self-examination of skin monthly is secondary prevention. D Sunscreen also needs to be used on overcast days.

After two separate office visits, the nurse suspects that a patient is developing Stage 1 hypertension based on which consecutive blood pressure readings? a. Visit 1, 118/78; Visit 2, 116/76 b. Visit 1, 130/88; Visit 2, 134/88 c. Visit 1, 144/92; Visit 2, 150/90 d. Visit 1, 162/100; Visit 2, 166/104

A These readings are within normal limits. B These readings are prehypertension because the systolic pressures are 120 to 139 and diastolic pressures are greater than 80 mm Hg. C These readings are stage 1 because the systolic pressures are 140 to 159 and diastolic pressures are 90 mm Hg or greater. D These readings are stage 2 because the systolic pressures are greater than 160 and diastolic pressures are 100 mm Hg or greater.

A patient's blood pressure using the posterior tibial pulse is 104/72 while blood pressure using the brachial pulse is 112/84. This patient's ankle-brachial index (ABI) is _____.

ANS: 0.92 Posterior tibial systolic pressure (104) divided by the brachial systolic pressure (112) = 0.92. The systolic pressures are the numbers used to calculate the ABI

A patient tells the nurse that he has smoked 1 packs of cigarettes a day for 14 years. The nurse records this as _____ pack-years?

ANS: 21 1 packs of cigarettes 14 years = 21 pack-years

After assessment of the nose and paranasal sinuses, which finding requires further investigation by the nurse? a. Nasal septum off the midline b. Nose in the midline of the face c. Middle turbinates deep pink in color d. Noiseless exchange of air from each naris

ANS: A Feedback A A deviated septum is an abnormal finding that needs further investigation. B This is an expected finding. C This is a normal finding. D This is a normal finding

A patient has come to the clinic complaining of a "bump" behind his right ear. Upon inspection, the nurse notes a lesion that is elevated, solid, and 4 cm in diameter. What does the nurse call this lesion when she reports her findings to the health care provider? a. Tumor b. Nodule c. Keloid d. Papule

ANS: A Feedback A A tumor is an elevated and solid lesion, may or may not be clearly demarcated, extends deeper in the dermis, and greater than 2 cm in diameter. B A nodule is an elevated, firm, circumscribed lesion that extends deeper into the dermis than a papule and is 1 to 2 cm in diameter. C A keloid is an irregularly-shaped, elevated, progressively-enlarging scar that grows beyond the boundaries of the wound. D A papule is an elevated, firm, circumscribed area less than 1 cm in diameter

. A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment? a. S4 heart sound b. Clubbing of fingers c. Splitting of the S1 heart sound d. Pericardial friction rub

ANS: A Feedback A An S4 heart sound signifies a noncompliant or "stiff'' ventricle. Coronary artery disease is a major cause of a stiff ventricle. B Clubbing of fingers occurs due to chronic hypoxia rather than a stiff ventricle. C Splitting of the S1 heart sound indicates a valve problem rather than ventricular hypertrophy. When the mitral and tricuspid valves do not close at the same time, S1 sounds as if it were split into two sounds instead of one. D Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac.

A nurse notices a patient's chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately? a. Palpate for tracheal deviation. b. Auscultate for bronchovesicular breath sounds in the lung periphery. c. Palpate posterior thoracic muscles for tenderness. d. Auscultate for absence of breath sounds in the lung periphery.

ANS: A Feedback A Chest wall moving in during inspiration and out during expiration is paradoxical chest wall movement. It can be caused by a tension pneumothorax, which increases intrathoracic pressure in the thorax, causing tracheal deviation and indicating mediastinal shift. B Tension pneumothorax does not create bronchovesicular breath sounds in the lung periphery. C This is performed when the patient has air in the subcutaneous tissue or pleural friction rub. D Absent breath sounds may be found in pneumothorax, but if the patient has a tension pneumothorax, tracheal deviation is a more important sign.

When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve? a. Pupillary constriction to light b. Visual acuity c. Peripheral vision d. Presence of the red reflex

ANS: A Feedback A Cranial nerve III (oculomotor) controls pupillary dilation and constriction, as well as eyelid movement. Pupil dilation and ptosis may occur when CN III is impaired. B Cranial nerve II (optic) provides vision. C Cranial nerve II (optic) provides peripheral vision. D The red reflex is not controlled by cranial nerve III, but is created by a light illuminating the retina.

A nurse notices several reddish purple, nonblanchable spots of different sizes on the arms and legs of a patient with a low platelet count. How does the nurse distinguish ecchymosis from purpura? a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. b. Ecchymosis does not blanch and purpura does blanch. c. Ecchymosis has raised lesions and purpura has flat lesions. d. Ecchymosis is irregularly shaped and purpura is round

ANS: A Feedback A Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. This is an accurate statement. B Ecchymosis does not blanch and purpura does blanch. Both of these lesions are nonblanchable. C Ecchymosis has raised lesions and purpura has flat lesions. Both of these lesions are flat. D Ecchymosis is irregularly shaped and purpura is round. There is no specified shape for either type of lesion.

During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares? a. Enlarged and pale turbinates b. Polyps within the nares c. High vascularity of the turbinates d. Dry and dull turbinates

ANS: A Feedback A Enlarged and pale turbinates are expected findings for allergic rhinitis. B Polyps within the nares is not an expected finding. C High vascularity of the turbinates is not an expected finding. D Dry and dull turbinates is not an expected finding.

A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of healing. What is the most appropriate action for the nurse at this time? a. Obtain further data now to rule out abuse. b. Remind parents that toddlers are clumsy and may fall, causing bruising. c. Determine if this toddler has a coagulation disorder. d. Recommend further observation at future visits.

ANS: A Feedback A Further investigation is needed to rule out abuse. The important clue is bruises in different stages in healing. Injuries to the skin are generally recognized in three forms: bruises, bites, and burns. B Remind parents that toddlers are clumsy and may fall, causing bruising. The important clue is bruises in different stages of healing. C A coagulation disorder can be ruled out by a laboratory test for platelets. D Recommend further observation at future visits. Action must be taken during this

When the patient's chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? a. Purplish-red pinpoint lesions b. Deep purplish or red patches of skin c. Small raised fluid-filled pinkish nodules d. Generalized reddish discoloration of an area of skin

ANS: A Feedback A Purplish-red pinpoint lesions describes the appearance of petechiae. B Petechiae are pinpoints, not as large as a patch. C Petechiae are pinpoints, not raised as a nodule. D Petechiae are pinpoints, not generalized.

. A nurse learns from a report that a patient has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve? a. Second intercostal space, right sternal border b. Second intercostal space, left sternal border c. Fourth intercostal space, left sternal border d. Fifth intercostal space, left midclavicular line

ANS: A Feedback A Second intercostal space, right sternal border is the location for listening to the aortic valve. B Second intercostal space, left sternal border is the location for listening to the pulmonic valve. C Fourth intercostal space, left sternal border is the location for listening to the tricuspid valve. D Fifth intercostal space, left midclavicular line is the location for listening to the mitral valve.

During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data? a. "Does the sputum have an odor?" b. "Do you have chest pain when you take a deep breath?" c. "Have you also experienced tightness in your chest?" d. "Have you coughed up any blood?"

ANS: A Feedback A Sputum with odor and sputum production with change of position is associated with lung abscess or bronchiectasis. B Chest pain on deep breathing is associated with pleural lining irritation. C Tightness in the chest is associated with asthma. D Coughing up rust-colored sputum is associated with pneumonia, but coughing up blood may be associated with lung cancer

. A nurse notices a patient's nails are thin and depressed with the edges turned up. What additional abnormal data should the nurse expect to find on this patient? a. Pale conjunctiva b. Jaundice c. Ecchymosis d. Rashes

ANS: A Feedback A The abnormal nail finding was koilonychia, which occurs in patients with anemia who frequently have pale conjunctiva. B Jaundice is due to increased serum bilirubin, indicating liver or gallbladder disease, and does not create changes in nail structure. C Ecchymosis occurs after trauma to the blood vessel resulting in bleeding under the tissue and does not cause changes in nail structure. D Rashes indicate an inflammation or allergic reaction that does cause changes in the nails.

After taking a brief health history, a nurse needs to complete a focused assessment on which patient? a. A male who works as a painter b. A male who plays basketball and hockey c. A female who recently moved into a college dormitory d. A female who has a history of gout

ANS: A Feedback A The fumes and chemicals from the paint may expose the patient to respiratory irritants. A baseline pulmonary assessment needs to be documented. B This patient is not at risk for pulmonary disease. C This patient is not at risk for pulmonary disease. D This patient is not at risk for pulmonary disease.

Which cranial nerve is assessed by using the Snellen visual acuity chart? a. Optic cranial nerve (CN II) b. Oculomotor cranial nerve (CN III) c. Abducens cranial nerve (CN IV) d. Trochlear cranial nerve (CN VI)

ANS: A Feedback A The optic cranial nerve (CN II) provides vision tested by the Snellen visual acuity chart. B CN III controls pupillary constriction, eyelid movement, and eyeball movement. C CN IV controls eyeball movement. D CN VI controls eyeball movement.

A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares? a. Clear b. Malodorous c. Yellow d. Green

ANS: A Feedback A The patient has allergic rhinitis, which produces clear drainage. B Malodorous drainage is associated with bacterial infection, which is not consistent with the history given by this patient. C Yellow drainage is associated with bacterial infection, which is not consistent with the history given by this patient. D Green drainage is associated with bacterial infection, which is not consistent with the history given by this patient.

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding? a. The extraocular muscles of both eyes are intact. b. The cornea of each eye is transparent. c. The sclera of each eye is clear. d. The consensual reaction of both eyes is intact.

ANS: A Feedback A The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. B The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. C The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. D Consensual reaction involves constriction of pupils

When inspecting a patient's nasal mucous membrane, which finding does the nurse expect to see? a. Deep pink turbinates b. Red, edematous mucous membranes c. Septum that angles to the left d. Clear exudate

ANS: A Feedback A These are expected for a nasal inspection. B These indicate a local infection within the nose. C This is abnormal. D This occurs with nasal allergies

A patient reports having migraine headaches on one side of the head that often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient reports which associated symptoms of migraine headaches? a. Nausea, vomiting, or visual disturbances b. Nasal stuffiness or discharge c. Ringing in the ears or dizziness d. Red, watery eyes or drooping eyelids

ANS: A Feedback A These are symptoms associated with migraine headaches. B This is a symptom associated with cluster headaches rather than migraine headaches. C These symptoms are not associated with migraine headaches. D These are symptoms associated with cluster headaches rather than migraine headaches

Which patient should the nurse assess first? a. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right. b. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever. c. The patient who is short of breath, using pursed-lip breathing, and in a tripod position. d. The patient whose respiratory rate is 20 breaths/min, and has 8-word dyspnea and expiratory wheezes.

ANS: A Feedback A This is a description of a left tension pneumothorax. The key manifestation is deviation of the trachea from midline, which indicates high intrathoracic pressure from the left that is pushing the mediastinum out of alignment. The respiratory rate indicates tachypnea. B This is a description of a patient with pneumonia who needs to be examined, but this is not a life-threatening condition. C This is a description of a patient with emphysema, a chronic disease. This patient may have these manifestations frequently and does not need to be examined immediately. D This is a description of a patient who is having an asthma attack, but it is not a life threatening attack; the respiratory rate is the upper limits of normal; the dyspnea is abnormal, but not far from normal; and the wheezing is on expiration

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness? a. "I felt faint, like I was going to pass out." b. "It felt like I was on a merry-go-round." c. "The room seemed to be spinning around." d. "My body felt like it was revolving and could not stop."

ANS: A Feedback A This is a description of lightheadedness, a form of dizziness. B This is consistent with objective vertigo because it includes a sensation of motion. C This is consistent with objective vertigo because it includes a sensation of motion. D This is consistent with subjective vertigo because it includes a sensation of one's body rotating in space.

While giving a history, a patient reports itching arms, legs, and chest after using a new soap. What manifestations does the nurse expect to find on the arms, legs, and chest when inspecting this patient's skin? a. Elevated irregularly shaped areas of edema of variable diameter b. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameter c. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with serous fluid d. Elevated, firm circumscribed areas less than 1 cm in diameter

ANS: A Feedback A This is a description of wheals, which occur as a result of allergic reactions. B This is a description of plaque. C This is a description of a vesicle. D This is a description of a papule.

A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patient's lungs? a. Vesicular breath sounds heard in peripheral lung fields b. Bronchial breath sounds heard over the bronchi c. Bronchovesicular breath sounds heard over the apices d. Rhonchi heard over the main bronch

ANS: A Feedback A Vesicular breath sounds heard in peripheral lung fields are an expected finding for healthy lungs. B Bronchial breath sounds are heard over the trachea. C Bronchovesicular breath sounds are heard anteriorly near the sternal border first and second intercostals space. D Rhonchi are adventitious sounds indicating secretions in the bronchi

4. What signs of cyanosis does a nurse inspect for in a dark-skinned patient? a. Ashen-gray color of the oral mucous membranes b. Blue color in the nail beds c. Ashen-blue color in the palms and soles d. Blue-gray color in the ear lobes and lips

ANS: A Feedback A Cyanosis is manifested by ashen-gray color of the oral mucous membranes and nail beds in a dark-skinned patient. B An ashen-gray color of the nail beds is expected in a dark-skinned patient, rather than blue. C An ashen-gray color of the oral mucous membranes and nail beds are expected in a dark-skinned patient. D An ashen-gray color of the oral mucous membranes and nail beds are expected in a dark-skinned patient.

A nurse expects which finding during a cardiovascular assessment of a healthy adult? a. Visible, consistent pulsations of the jugular vein b. Pink nail beds with a 90-degree angle at the base c. Capillary refill of the toes greater than 5 seconds d. Bruits heard on auscultation of the carotid arteries

ANS: A Feedback A Visible, consistent pulsations of the jugular vein is an expected finding. B Pink nail beds with a 90-degree angle at the base is not a normal finding; the angle at the base should be 160 degrees. C Capillary refill of the toes greater than 5 seconds is not a normal finding. Capillary refills should be 2 seconds or less. D Bruits heard on auscultation of the carotid arteries is not a normal finding. Bruits indicate occlusion of a blood vessel.

A patient is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis? a. Unilateral foul-smelling drainage b. Bilateral purulent green-yellow discharge c. Bilateral bloody discharge d. Unilateral watery discharge

ANS: A Feedback A This is consistent with presence of a foreign object in one side of the nose. B This is consistent with a nasal or sinus infection. C This is consistent with localized trauma, such as a nasal fracture. D This is consistent with a history of head injury and may indicate skull fracture.

Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply. a. Lips appear pink, smooth, moist, and symmetric b. Teeth are white, yellow, or gray, with smooth edges c. Exposed tooth neck and brown spots between teeth d. Slight roughness on the dorsum of the tongue e. Hard palate appears smooth, pale, and immovable f. Mucous membranes are dry and intact

ANS: A, B, D, E Correct: These are all expected findings from a mouth assessment of a healthy adult. Incorrect: Receding gums expose tooth neck and may indicate gingival disease. Brown spots may indicate caries. Dry and intact mucous membranes may indicate dehydration.

Nurses inquire about lifestyle behaviors in those patients with specific risk factors for cataracts. Which characteristics are associated with risk factors for cataracts? Select all that apply. a. Smoking more than 20 cigarettes a day b. Having parents with cataracts c. Chronic consumption of alcohol d. Having a chronic disease, such as diabetes mellitus e. Being Asian f. Being a man

ANS: A, C, D Correct: These are all risk factors for cataracts. Incorrect: Having parents with cataracts is not a genetic or familial disorder. Being Asian or a man are not risk factors, but being an African-American or being a woman are risk factors.

Which questions are appropriate to ask a patient when performing a symptom analysis for a rash? Select all that apply. a. "When did the rash first start?" b. "Do you have a family history of rashes?" c. "What makes the rash worse?" d. "What do you do to make your rash better?" e. "Describe the sensation from the rash, does it burn or itch?" f. "Describe what the rash looked like initially."

ANS: A, C, D, E, F Correct: These are questions asked in a symptom analysis that includes the following variables: onset of symptoms, location and duration of symptoms, characteristics, severity of symptoms, related symptoms, alleviating factors, aggravating factors, and attempts at selftreatment. Incorrect: This question relates to the patient's history.

. A nurse is assessing the eyes of a healthy 72-year-old adult. What findings does the nurse expect? Select all that apply. a. Bulbar conjunctiva pink and clear, with small red vessels noted b. Sclera yellow and moist, cornea transparent c. Extraocular movement symmetric with peripheral vision noted d. Newspaper held at 18 inches to see clearly e. Sclera visible between upper lid and iris f. Gray to white circle noted where the sclera merges with the cornea g. Light reflects on the cornea at 12 o'clock in each eye

ANS: A, C, G Correct: These are expected findings from an assessment of the eyes of a healthy adult. Incorrect: Sclera should be white and moist. Newspaper held at 18 inches to see clearly is due to presbyopia due to the patient's age. Patient must hold paper further away to see clearly. The upper lid should cover the upper part of the iris. Sclera is visible in hyperthyroidism. A gray to white circle is arcus senilis, which is an abnormal finding in older adults

A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? Select all that apply. a. Thoracic expansion that is symmetric bilaterally b. Respiratory rate of 24 breaths/min c. Bronchophony revealing clear voice sounds d. Breath sounds clear with vesicular breath sounds heard over most lung fields e. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter f. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine

ANS: A, D, E, F Correct: These are expected findings from a lung and respiratory assessment of a healthy adult . Incorrect: A respiratory rate of 24 breaths/min is considered tachypnea. Bronchophony revealing clear voice sounds is not performed unless there is an indication of consolidation of the lung, or if there was an abnormal finding of tactile fremitus. The expected finding is muffled voiced sounds rather than clear

A nurse suspects a patient has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use? a. Place the palmar side of each hand against the lateral thorax at the level of the waist, ask the patient to take a deep breath, and observe lateral movement of the hands. b. Place both thumbs on either side of the patient's T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs. c. Place both thumbs on either side of the patient's T7 to T8 spinal processes, extend fingers laterally, ask the patient to exhale deeply, and observe lateral inward movement of the thumbs. d. Place the palmar side of each hand on the shoulders of the patient, ask the patient to sit up straight and take a deep breath, and observe symmetric movement of the shoulders.

ANS: B Feedback A The palms of the hands are not used and hands are not placed on the lateral thorax. B This is the correct technique to assess thoracic expansion. C The thoracic level is too high and the patient does not exhale. D The hands are not placed on the shoulders

2. A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a. Yellowish color in the axilla and groin b. Yellow pigmentation in the sclera c. Very pale skin on the palms d. Ashen-gray color in the oral mucous membranes

ANS: B A Instead of the axilla and groin, assess the sclera of the eyes, fingernails, palms of hands, and oral mucosa. B Jaundice is manifested by a yellowish color in the sclera of the eyes and palms of the hands in both light- and dark-skinned patients. C Pale skin may indicate anemia, but not jaundice. Yellow color of the palms indicates jaundice. D Ashen-gray color may be seen in dark-skinned patients who are cyanotic.

A teenager comes to the clinic complaining about the whiteheads and blackhead on his face interfering with his social life. During the examination the nurse palpates an enlarged submental lymph node. Where is this lymph node located? a. In front of the ear b. Under the mandible c. At the base of the skull d. Along the angle of the jaw

ANS: B Feedback A This is the location of the preauricular lymph nodes. B This is the location of the submental lymph node. C This is the location of the occipital lymph nodes. D This is the location of the parotid lymph nodes.

A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination? a. Foul-smelling drainage b. Purulent green-yellow drainage c. Bloody drainage d. Watery drainage

ANS: B Feedback A Foul-smelling drainage is consistent with a foreign object in the nose. B Purulent green-yellow drainage is consistent with a nasal or sinus infection. C Bloody drainage is consistent with trauma to the nose. D Watery drainage is consistent with a nasal allergy

Which patient in the eye clinic should the nurse assess first? a. The patient who reports a gradual clouding of vision b. The patient who complains of sudden loss of vision c. The patient who complains of double vision d. The patient who complains of poor night vision

ANS: B Feedback A A gradual clouding of vision is a symptom of cataracts that develop slowly and do not require immediate assessment. B Sudden vision loss may indicate a detached retina and requires immediate referral. C Double vision is a symptom of cataracts that develop slowly and do not require immediate assessment. D Poor night vision is a symptom of cataracts that develop slowly and do not

When inspecting a patient's posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal? a. Both tonsils have a smooth surface. b. Left and right tonsils meet at the midline. c. Left and right tonsils extend beyond the posterior pillars. d. Both tonsils have a glistening appearance.

ANS: B Feedback A A smooth surface is expected for the tonsils. B This indicates an enlargement documented as 4+. C This is an expected finding for the tonsils. D This is an expected finding for the tonsils.

A nurse auscultates low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time? a. Palpate the posterior thorax for vocal fremitus. b. Ask the patient to cough and repeat auscultation. c. Auscultate the posterior thorax for vocal sounds. d. Percuss the posterior thorax for tone.

ANS: B Feedback A An abnormal vocal fremitus (decreased or increased vibrations) is not expected for this patient. B The sounds indicate rhonchi, or secretions in the bronchi. The first action to take is to determine if the rhonchi clear with coughing. If the rhonchi clear, there is no need to further investigate this finding. C Abnormal vocal sounds (clear and loud sounds) are not expected for this patient. D An abnormal percussion tone (hyperresonance or dull) is not expected for this patient.

A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma? a. Nonblanching lesion b. Irregular border c. Diameter less than 5 mm d. Black color of the lesion

ANS: B Feedback A Blanching is not assessed in malignant skin lesions. B Irregular border or poorly defined border is an indication of a malignancy. C Diameter of a malignant skin lesion is usually greater than 6 mm. D Melanoma is a variety of colors.

The nurse is comparing pitch and duration of the various types of a patient's breath sounds and recognizes which one of these as an expected finding? a. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory ratio. b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versusinspiratory ratio. c. Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versusexpiratory ratio. d. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio. s.

ANS: B Feedback A Bronchial sounds are high pitched with a duration of 1:2 inspiration-to-expiration is the correct statement. B Bronchovesicular sounds having a moderate pitch and 1:1 expiratory-versusinspiratory ratio is a normal finding. C Vesicular sounds are low pitched with a duration of 2.5:1 inspiration-to-expiration is the correct statement. D Wheezes are high-pitched and have no specific duration because they are adventitious sound

Which patient's statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina? a. "No, I have not done anything to strain chest muscles." b. "If I take a deep breath, the pain gets much worse." c. "This pain feels like there's an elephant sitting on my chest." d. "Whenever this pain happens, it goes right away if I lie down."

ANS: B Feedback A Chest pain from muscle strain may be aggravated by movement of arms. B The chest pain from pericarditis is aggravated by deep breathing, coughing, or lying supine. C "This pain feels like there's an elephant sitting on my chest" is associated with a myocardial infarction. D Chest pain relieved by rest occurs with angina.

A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patient's integumentary system, what finding should the nurse correlate to this respiratory disease? a. Dry, flaky skin b. Clubbing of the fingers c. Hypertrophy of the nails d. Hair loss from the scalp

ANS: B Feedback A Dry, flaky skin occurs with dehydration. B Clubbing of the fingers develops due to chronic hypoxemia, which occurs in chronic obstructive pulmonary disease. C Hypertrophy of the nails occurs with repeated trauma. D Hair loss from the scalp is alopecia, which occurs with many systemic diseases, but not chronic pulmonary disease.

A nurse notices multiple lesions on the back of a patient's left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. How does the nurse document these lesions? a. As multiple macules on the dorsum of the left hand b. As multiple vesicles on the dorsum of the left hand c. As several patches on the left hand d. As several bullae on the dorsum of the left hand

ANS: B Feedback A Macules are flat, circumscribed areas that are a change in the color of the skin and are less than 1 cm in diameter. B Vesicles are elevated, circumscribed, superficial (do not extend into dermis), filled with serous fluid, and less than 1 cm in diameter. This documentation tells the number and location of the lesions. C Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in diameter. This documentation does not include location of lesions. D Bullae are large vesicles greater than 1 cm in diameter

While assessing edema on a male patient's lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patient's leg. How does the nurse document this finding? a. No edema b. 1+ edema c. 2+ edema d. 3+ edema

ANS: B Feedback A No pit left after palpation indicates no edema. B A barely perceptible pit is detected after palpation. C A deeper pit that rebounds in a few seconds after palpation is 2+ edema. D A deep pit that rebounds in 10 to 20 seconds after palpation is 3+ edema.

Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border? a. Pulmonic b. Tricuspid c. Mitral d. Aortic

ANS: B Feedback A Pulmonic valve sounds are best heard in the second intercostal space at the left of the sternal border. B Tricuspid valve sounds are best heard in the fourth intercostal space at the left of the sternal border. C Mitral valve sounds are best heard in the fifth intercostal space at the midclavicular line. D Aortic valve sounds are best heard in the second intercostal space at the right of the sternal border

A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings. How will the nurse recognize the characteristics of keloids? a. Roughened and thickened scales involving flexor surfaces b. Hypertrophic scarring extending beyond the original wound edges c. Thin, fibrous tissue replacing normal skin following injury d. Loss of the epidermal layer, creating a hollowed-out or crusted area

ANS: B Feedback A Roughened and thickened scales involving flexor surfaces is a description of lichenification. B Hypertrophic scarring extending beyond the original wound edges is a description of a keloid. C Thin, fibrous tissue replacing normal skin following injury is a description of a scar. D Loss of the epidermal layer, creating a hollowed-out or crusted area is a description of excoriation.

During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patient's eyes? a. Anterior chamber depth is shallow. b. Red reflex is absent. c. Extraocular muscle movement is asymmetric. d. Retinal arteries are wider than retinal veins.

ANS: B Feedback A Shallow anterior chamber depth occurs in glaucoma. B The symptoms suggest cataracts. The red reflex cannot be seen because the light cannot penetrate the opacity of the lens. C Extraocular muscle movement is asymmetric. Cataracts affect the lens rather than the eye muscles. D Retinal arteries are wider than retinal veins. Cataracts affect the lens rather than the retinal vessels

A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse's appropriate response? The 128 represents the pressure in your blood vessels when: a. "The ventricles relax and the aortic and pulmonic valves open." b. "The ventricles contract and the mitral and tricuspid valves close." c. "The ventricles contract and the mitral and tricuspid valves open." d. "The ventricles relax and the aortic and pulmonic valves close."

ANS: B Feedback A The aortic and pulmonic valves open during systole, but ventricles fill during diastole. B During systole the ventricles contract, creating a pressure that closes the atrioventricular (AV) valves (mitral and tricuspid). C During systole the ventricles contract, creating a pressure that closes the AV valves (mitral and tricuspid). D The ventricles are relaxed and the aortic and pulmonic valves close during diastole, rather than systole.

What does the S2 heart sound represent? a. The beginning of systole. b. The closure of the aortic and pulmonic valves. c. The closure of the tricuspid and mitral values d. A split heard sound on exhalation

ANS: B Feedback A The beginning of systole is the S1 heart sound. B The second heart sound is made by the closing of these valves, which indicates the beginning of diastole. C The tricupid and mitral valves create the S1 heart sound. D A split sound on exhalation is not a correct statement.

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 2 o'clock position and in the left cornea at the 10 o'clock position. Based on these data, the nurse should take what action? a. Document these findings as normal. b. Perform the cover-uncover test. c. Perform the confrontation test. d. Document these findings as abnormal.

ANS: B Feedback A The findings are abnormal. The light should appear in the same location in each cornea. B The nurse is performing the corneal light reflex test and the findings are abnormal. Thus, when the corneal light reflex is asymmetric, the cover-uncover test is performed to determine which eye has the weak extraocular muscle(s). C The confrontation test is used to assess peripheral visual fields and is not appropriate to perform when the corneal light reflex is asymmetric. D The asymmetric corneal light reflex is abnormal, but the cover-uncover test should follow the abnormal finding to determine which eye has the weak extraocular muscle(s)

. A patient has had an infected facial wound for more than 3 months. How does the nurse expect the patient's enlarged lymph nodes to feel? a. Soft, edematous, and tender b. Round, tender, and movable c. Hard, nontender, and nonmobile d. Irregularly shaped, tender, and firm

ANS: B Feedback A These are not characteristics of lymph nodes associated with inflammation. B These are characteristics of enlarged lymph nodes associated with inflammation. C These are characteristics of enlarged lymph nodes associated with a malignancy. D These are not characteristics of lymph nodes associated with inflammation.

A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection? a. Tinnitus, vertigo, and dizziness b. Clear drainage from the ear and nose c. Loss of hearing and smell d. Purulent drainage from the ear and bloody drainage from the nose

ANS: B Feedback A These are subjective and gathered during the history rather than inspection. Although the patient may report having dizziness or vertigo, the finding of tinnitus is inconsistent with a basilar skull fracture. B This may occur after a basilar skull fracture. The clear drainage may be cerebrospinal fluid. C This is inconsistent with a basilar skull fracture. D Purulent drainage is inconsistent with a basilar skull fracture, and bloody drainage usually does not come from the nose, but may be seen from the ear.

How does the nurse test the function of the patient's spinal accessory nerve (CN XI)? a. Ask the patient to stick out the tongue and move it side to side. b. Ask the patient to shrug the shoulders against the resistance of the nurse's hands. c. Ask the patient to open the mouth and observe the uvula rise when he says "ah." d. Ask the patient to move the chin to the chest and then up toward the ceiling.

ANS: B Feedback A This is a test of the hypoglossal cranial nerve (XII). B This is the correct technique for assessing the spinal accessory cranial nerve (XI). C This is a test for cranial nerves IX (glossopharyngeal) and X (vagus). D This technique assesses the range motion of the neck

In assessing a patient with head injury, the nurse should be most concerned with which finding? a. Pain on palpation of the scalp b. Unilateral clear, watery nasal discharge c. A scalp laceration at the sight of injury d. Complaints of dizziness

ANS: B Feedback A This is expected after a head injury and is not a cause for concern. B This may be cerebrospinal fluid, indicating a skull fracture. C This is expected after a head injury and is not a cause for concern. D This is expected after a head injury and is not a cause for concern.

During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patient's eyes. How does a nurse document this finding? a. An expected racial variation b. Nystagmus c. Exophthalmus d. Myopia

ANS: B Feedback A This is not a racial variation. B An involuntary rhythmical, horizontal movement of the patient's eyes is a description of nystagmus. C Exophthalmus is the bulging of the eyeball forward, seen in patients with hyperthyroidism. D Myopia is an elongated eyeball found in patients who are nearsighted.

The nurse palpates the patient's jaw movement, placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What additional request does the nurse ask the patient to do to assess the jaw? a. Clinch the jaws together as tightly as possible. b. Move the lower jaw from side to side. c. Open the mouth as wide as possible, like a yawn. d. Move the lower jaw forward and backward several times.

ANS: B Feedback A This is not an assessment technique for the jaw. B This is the technique to complete assessment of the motion of the jaw. C This was completed when the nurse asked the patient to open and close the mouth. D This is not an assessment technique for the jaw.

A nurse observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the student requires a corrective comment from the nurse? a. Instructing the patient to cover the ear not being tested b. Standing beside the patient on the side of the ear being tested c. Shielding the mouth to prevent the patient from reading lips d. Whispering one or two syllable words and ask the patient to repeat what is heard

ANS: B Feedback A This is the correct technique. B The student nurse should stand 1 to 2 feet in front or to the side of the patient C This is the correct technique. D This is the correct technique.

To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm? a. "Rhythm 100 beats/min" b. "Irregular rhythm" c. "Rhythm noted at +2" d. "Bounding rhythm"

ANS: B Feedback A This notation refers to the rate rather than the rhythm. B The rhythm should be an equal pattern or spacing between beats. Irregular rhythms without any pattern should be noted. C This notation refers to the amplitude rather than the rhythm. D This notation refers to the contour rather than the rhythm.

A nurse notices that the angle of the patient's proximal nail fold and the nail plate are almost a flat line; about 160 degrees. How does the nurse interpret this finding? a. This patient has chronic pulmonary disease. b. This is an expected finding. c. This is due to stress to the nails. d. This is associated with anemia.

ANS: B Feedback A This patient has chronic pulmonary disease, which causes clubbing (when the angle of the nail base exceeds 180 degrees). B The expected angle of the nail base is 160 degrees. C This answer describes Beau lines, which appear as a groove or transverse depression running across the nail. It results from a stressor that temporarily impairs nail formation. D This is associated with anemia, which causes koilonychia, a thin, depressed nail with the lateral edges turned upward

A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? a. Make sure the bell of the stethoscope is used, rather than the diaphragm. b. Hold stethoscope firmly to prevent movement when placed over chest hair. c. Ask the patient not to talk while the nurse is listening to the lungs. d. Change the patient's position to ensure accurate sounds.

ANS: B Feedback A Using the bell will provide inaccurate sounds, but not mimic crackles. B The stethoscope moving even slightly on chest hair can mimic the sound of crackles. C When the patient talks during auscultation, it does interfere with data collection, but the sound is a muffled voice. D Changing the position will not affect the outcome of the assessment if the initial problem remains

The patient describes her chest pain as "squeezing, crushing, and 12 on a scale of 10." This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms? a. Tachycardia, tachypnea, and hypertension b. Dyspnea, diaphoresis, and palpitations c. Hyperventilation, fatigue, anorexia, and emotional strain d. Fever, dyspnea, orthopnea, and friction rub

ANS: B Feedback A Tachycardia, tachypnea, and hypertension are symptoms associated with cocaineinduced chest pain. B Dyspnea, diaphoresis, and palpitations are symptoms associated with unstable angina. C Hyperventilation, fatigue, anorexia, and emotional strain are symptoms associated with panic disorder. D Fever, dyspnea, orthopnea, and friction rub are symptoms associated with pericarditis.

. On inspection, the nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? Select all that apply. a. Inspiratory wheezing found on auscultation b. Hyperresonance heard on percussion c. Decreased breath sounds heard on auscultation d. Deceased diaphragmatic excursion on percussion e. A sharp, abrupt pain reported when the patient breathes deeply f. Decreased to absent vibration on vocal fremitus

ANS: B, C, D, F Correct: These are all indications of enlargement or destruction of alveoli that occurs in emphysema. Air is trapped, which increases the anteroposterior to lateral diameter creating a barrel chest, and pushes the diaphragm down decreasing the excursion and causing hyperresonance. The destroyed alveoli decrease the breath sounds and create absent vibration on vocal fremitus. Incorrect: Inspiratory wheezing found on auscultation indicates narrowed airways as found in asthma. A sharp, abrupt pain reported when the patient breathes deeply is pleuritic chest pain associated with pleural lining irritation that may occur in a patient with pleurisy or pneumonia.

A patient with heart failure reports having a cough with frothy sputum and awakening during the night to urinate. Based on this information, what abnormal data might this nurse expect to find during an examination? Select all that apply. a. S4 heart sound b. Dyspnea c. Jugular vein distention d. Pericardial friction rub e. Edema of ankle and feet at the end of the day f. S3 heart sound

ANS: B, C, E, F Correct: All of these manifestations are consistent with fluid overload that occurs in heart failure because the cardiac output is decreased. Incorrect: S4 heart sounds signifies a noncompliant or "stiff'' ventricle. Hypertrophy of the ventricle precedes a noncompliant ventricle. Also, coronary artery disease is a major cause of a stiff ventricle. Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac.

During a health fair, the nurse is alert for which risk factors for hypertension? Select all that apply. a. Excessive protein intake b. Having parents with hypertension c. Excessive alcohol intake d. Being Asian e. Experiencing persistent stress f. Elevated serum lipids

ANS: B, C, E, F Correct: These are all risk factors for hypertension. Incorrect: Excessive protein is not a risk factor for hypertension, but excessive sodium intake is a risk factor. Being Asian is not a risk factor, but being African-American is a risk factor

What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select all that apply. a. Heart rate of 102 beats/min b. S1 and S2 present with regular rhythm c. Capillary refill greater than 3 seconds d. Blood pressure of 124/86 e. Warm, elastic turgor f. Pulse of smooth contour with 2+ amplitude

ANS: B, E, F Correct: These are all expected findings. Incorrect: A heart rate of 102 beats/min is tachycardia. Capillary refill should be 2 seconds or less. Blood pressure of 124/86 is prehypertension. Normal is less than 120 and less than 80 mm Hg.

During an examination of the head and neck of a healthy adult, the nurse expects which findings? Select all that apply. a. Small red lesions with white flakes scattered on the scalp b. The head and facial bones are proportional for the size of the body c. Depressions palpated on the right and left sides over the parietal bones d. Head held flexed 15 degrees to the left e. Face and jaw are symmetric and proportional f. Temporomandibular joint moves smoothly

ANS: B, E, F Correct: These are expected findings from an assessment of the head of a healthy adult. Incorrect: Small red lesions with white flakes scattered on the scalp is an abnormal finding. The scalp should be intact without lesion or flakes. Depressions palpated on the right and left sides over the parietal bones is an abnormal finding. Perhaps this patient had skull tongs from cervical traction at one time. Head held flexed 15 degrees to the left is an abnormal finding. The head should be erect

1. What findings does the nurse expect when assessing skin, hair, and nails of a healthy male adult? Select all that apply. a. Transverse depression noticed across nails b. Scalp is bald c. Elevated, firm, circumscribed area less than 1 cm wide found on the fingers d. Purpura and ecchymosis are noticed on arms and legs e. Freckles are noted on face, back, arms, and legs f. Skin turgor is elastic

ANS: B, E, F Correct:Scalp is bald; freckles are noted on face, back, arms and legs; and skin turgor is elastic . These are expected findings for a healthy adult male. Incorrect: Transverse depression across the nails describes Beau lines. It results from a stressor that temporarily impairs nail formation. An elevated, firm, circumscribed area, less than 1 cm wide on the fingers describes a papule, such as a wart. Purpura and ecchymosis on arms and legs are indications of bleeding.

Which patient does the nurse identify as the one at greatest risk for hypertension? a. Woman with coronary artery disease b. Hispanic male c. Obese male with diabetes mellitus d. Postmenopausal woman

ANS: C Feedback A Although hypertension is a risk factor for coronary artery disease, coronary artery disease is not a risk factor for hypertension. B Although male gender is a risk factor, African-American men have a greater risk than Hispanic men. C Obese men with diabetes mellitus have three risk factors: obesity, gender, and comorbidity of diabetes mellitus. D Postmenopausal women do not have an increased risk for developing hypertension.

A nurse who is auscultating a patient's heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding? a. An opening snap b. A diastolic murmur c. A systolic murmur d. A pericardial friction rub

ANS: C Feedback A An opening snap is caused by the opening of the mitral or tricuspid valve and is an abnormal sound heard in diastole when either valve is thickened, stenotic, or deformed. The sounds are high pitched and occur early in diastole. B A diastolic murmur is heard after the S2 heart sound at the beginning of diastole. C The blowing sound is a murmur. The nurse determines whether it is a systolic or a diastolic murmur based on where it is heard during the cardiac cycle. S1 indicates the beginning of systole; the sound is made by the closing of the mitral and tricuspid valves, which is followed by ventricular contraction or systole. D Pericardial friction rubs have a rubbing sound that is usually present in both diastole and systole, and is best heard over the apical area.

Which pulse may be a challenge for a nurse to palpate? a. Temporal b. Femoral c. Popliteal d. Dorsalis pedis

ANS: C Feedback A The temporal pulse is palpated over the temporal bone on each side of the head. B For the femoral pulse, palpate below the inguinal ligament, midway between the symphysis pubis and anterior superior iliac. C For the popliteal pulse, palpate the popliteal artery behind the knee in the popliteal fossa to assess perfusion. This pulse may be difficult to find. D For the dorsalis pedis pulse, palpate on the inner aspect of the ankle below and slightly behind the medial malleolus (ankle bone)

A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time? a. Auscultate the temporal arteries for bruits. b. Palpate the arteries with the patient in supine position. c. Document this as an expected finding. d. Measure the patient's blood pressure.

ANS: C Feedback A This is not necessary for this patient at this time. B This is not necessary for this patient at this time. C These are consistent with expected assessment. D This will be done as a part of the assessment, but does not relate to the expected palpation of this patient's temporal arteries.

A nurse determines that a patient's jugular venous pressure is 3.5 inches. What additional data does the nurse expect to find? a. Weight loss b. Tented skin turgor c. Peripheral edema d. Capillary refill greater than 5 seconds

ANS: C Feedback A Weight loss occurs with loss of fluid rather than fluid overload. B Tented skin turgor occurs with fluid loss rather than fluid overload. C The pressure should not rise more than 1 inch (2.5 cm) above the sternal angle. A pressure of 3.5 inches indicates fluid volume excess, which causes peripheral edema due to excessive fluid in blood vessels. D Capillary refill greater than 5 seconds occurs with arterial insufficiency rather than fluid overload.

When assessing a patient with aortic valve stenosis, the nurse listens for which sound to detect a thrill? a. Sustained thrust of the heart against the chest wall during systole b. Visible sinking of the tissues between and around the ribs c. Fine, palpable vibration felt over the precordium d. Bounding pulse noted bilaterally

ANS: C Feedback A A sustained thrust of the heart against the chest wall during systole is a description of a lift. B A visible sinking of the tissues between and around the ribs is a description of a retraction. C A thrill is a palpable vibration over the precordium or artery. D A thrill feels like a palpable vibration rather than a bounding pulse.

3. How does the nurse recognize jaundice in a dark-skinned patient? a. Inspect the conjunctiva for ashen-gray color. b. Inspect the nail beds for a deeper brown or purple skin tone. c. Inspect the palms and soles for yellowish-green color. d. Inspect the oral mucous membrane for yellow color.

ANS: C Feedback A Ashen-gray color may be seen in dark-skinned patients who are cyanotic. B Brown or purple tone is seen in dark-skinned patients with erythema. C In dark-skinned patients, jaundice manifests as a yellowish-green color that can be seen most obviously in the sclera, palms of hands, and soles of feet. D Mucous membranes do not change color from jaundice.

While inspecting the skin, a nurse notices a lesion on the patient's upper right arm. What is the best way to document the size of this lesion? a. Compare its size to the size of a coin. b. Estimate its size to the nearest inch. c. Use a centimeter ruler to measure the lesion. d. Trace the lesion onto a piece of paper.

ANS: C Feedback A Comparing its size to the size of a coin can be done if no measurement tool is available, but the best way is to measure the lesion. B Estimating size to the nearest inch is not recommended due to inaccuracy. C A centimeter ruler to measure the size of lesions may be helpful. The lesion is documented based on its characteristics, including location, distribution, color, pattern, edges, flat or raised, and size. D Tracing the lesion onto a piece of paper can be done if no measurement tool is available, but the best way is to measure the lesion.

During inspection of a patient's upper back, the nurse notices three small, elevated superficial lesions filled with purulent fluid. How does the nurse document this finding? a. As three cysts on the upper back b. As several bullae on the back c. As three pustules on the upper back d. As three wheals on the upper back

ANS: C Feedback A Cysts are elevated, circumscribed, encapsulated lesions. B Bullae are vesicles greater than 1 cm in diameter. This documentation is not specific to the number or exact location. C Pustules are elevated, superficial lesions similar to vesicles but filled with purulent fluid. This is a specific documentation of what the nurse saw (three pustules) and their location (upper back). D Wheals are elevated irregular-shaped areas of cutaneous edema that are solid, transient, and of variable diameter.

A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose? a. Deviated septum b. Pale turbinates c. Perforated nasal septum d. Localized erythema and edema

ANS: C Feedback A Deviated septum may be from birth or trauma to the nose, but not from cocaine use. B Pale turbinates are an indication of allergies. C Perforated nasal septum develops from cocaine use. D Localized erythema and edema are nonspecific and indicate inflammation somewhere in the nose.

A nurse is having difficulty auscultating a patient's heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds? a. Lie in a supine position. b. Cough. c. Hold his or her breath for a few seconds. d. Sit up and lean forward.

ANS: C Feedback A Lying in a supine position will not reduce the noise of breathing. B Coughing may clear some secretions, but when the lung sounds are so noisy that the heart sounds are difficult to hear, coughing is not sufficient to eliminate the noise from respirations. C Holding the breath for a few seconds eliminates the noise of breathing long enough to hear several cardiac cycles of heart sounds. The holding of the breath can be repeated if needed to hear the heart sounds again. D Sitting up and leaning forward brings the heart closer to the thoracic wall, but will not eliminate noise produced by the lungs.

A nurse notices multiple lesions on a patient's left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. What kind of primary lesions are these? a. Macules b. Patches c. Vesicles d. Bullae

ANS: C Feedback A Macules are flat, circumscribed areas that are a change in the color of the skin and are less than 1 cm in diameter. B Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in diameter. C Vesicles are elevated, circumscribed, superficial (do not extend into dermis), filled with serous fluid, and less than 1 cm in diameter. This documentation tells the number and location of the lesions. D Bullae are large vesicles greater than 1 cm in diameter

When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound? a. A systolic murmur b. An S3 heart sound c. A friction rub d. An S4 heart sound

ANS: C Feedback A Most systolic murmurs are caused by obstruction of the outflow of the semilunar valves or by incompetent AV valves. B An S3 heart sound occurs when there is heart failure. C Two classic findings of pericarditis are pericardial friction rub and chest pain. D An S4 heart sound occurs when there is hypertrophy of the ventricle.

A nurse is assessing a patient's peripheral circulation. Which finding indicates venous insufficiency of this patient's legs? a. Paresthesias and weak, thin peripheral pulses b. Leg pain that can be relieved by walking c. Edema that is worse at the end of the day d. Leg pain that increases when the legs are lowered

ANS: C Feedback A Paresthesias and weak, thin peripheral pulses are characteristics of arterial insufficiencies rather than venous. B Pain caused by arterial insufficiency gets worse by walking, because walking requires additional arterial blood. C Dependent edema is an indication of venous insufficiency. D Arterial pain is relieved by lowering the leg and aggravated by elevating the legs.

What instructions does the nurse give the patient before using the Snellen visual acuity chart? a. "Remove your eyeglasses before attempting to read the lowest line." b. "Stand 10 feet from the chart and read the first line aloud." c. "Hold a white card over one eye and read the smallest possible line." d. "Squint if necessary to improve the ability to read the largest letters."

ANS: C Feedback A Patients should wear their glasses when visual acuity is tested. B The patient should stand 20 feet from the Snellen chart. C This is the appropriate technique for using the Snellen chart. D The patient should not squint to see the chart.

A nurse inspects a patient's hands and notices clubbing of the fingers. The nurse correlates this finding with what condition? a. Pulmonary infection b. Trauma to the thorax c. Chronic hypoxemia d. Allergic reaction

ANS: C Feedback A Pulmonary infection is acute and not associated with chronic hypoxia. B Trauma to the thorax is acute and not associated with chronic hypoxia. C Clubbing develops due to chronic hypoxemia, which occurs in chronic obstructive pulmonary disease. D Allergic reaction is acute and not associated with chronic hypoxia

A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patient's ears? a. Redness and edema of the pinna of the right ear b. Report of pain when the nurse manipulates the right ear c. Bulging and red tympanic membrane in the right ear d. Increased cerumen in the right ear canal .

ANS: C Feedback A Redness and edema of the pinna of the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. B Report of pain when the nurse manipulates the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. C Bulging and red tympanic membrane in the right ear is consistent with internal ear pain that may be associated with otitis media. D Increased cerumen in the right ear canal is not consistent with internal ear pain

During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patient's covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patient's eyes? a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered ey

ANS: C Feedback A Symmetry is tested by the corneal light reflex. B Visual acuity is tested using the Snellen chart. C This describes the confrontation test, which assesses peripheral vision. D Consensual reaction is tested by noticing the pupillary constriction of one eye when a light is being shown into the other eye

What findings does a nurse expect when inspecting and palpating a patient's nails? a. A nail base angle of not more than 90 degrees b. Whitish to clear nails in darker-skinned patients c. Nail surface is smooth and rounded d. Transverse depression running across the nails

ANS: C Feedback A The expected angle of the nail base is 160 degrees. B Patients with darker-pigmented skin typically have nails that are yellow or brown, and vertical banded lines may appear. C Nail surface that is smooth and rounded is an expected finding. D This is a description of Beau lines.

A nurse's presentation to patients on risk factors for oral cancer includes which fact? a. The peak incidence oral cancer is before 40 years of age. b. Women have a higher risk than men. c. Excessive alcohol consumption is a risk factor. d. Eating a low fiber diet is a risk factor.

ANS: C Feedback A There is increased incidence after age 40 with peak incidence between ages 64 and 74. B There is a 2:1 men-to-women incidence. C Seventy-five to eighty percent of individuals who develop oral cancer consume excessive amounts of alcohol. D A low fiber diet increases the risk for colon cancer, but not oral cancer.

A nurse assesses neck range of movement of several adults. Which patient has an expected range of motion of the neck? a. Patient A is unable to resist the nurse's attempt to move the head upright. b. Patient B bends the head to the right and left (ear to shoulder) 15 degrees. c. Patient C flexes chin toward the chest 45 degrees. d. Patient D hyperextends the head 30 degrees from midline.

ANS: C Feedback A This finding is abnormal. B This finding is abnormal. The patient should be able to laterally bend the head 40 degrees from midline in each direction. C This is an expected finding. D The patient should be able to hyperextend the head 55 degrees from midline

A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years? a. 10 b. 20 c. 40 d. 60

ANS: C Feedback A This incorrect calculation was made by dividing 20 years by 2 packs. B This is correct if the patient smoked 1 pack per day for 20 years. C Two packs of cigarettes 20 years = 40 pack-years. D This is correct if the patient smoked 3 packs per day for 20 years or 2 packs a day for 30 years

A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action? a. Document this finding as an abnormal finding. b. Assess the patient for accommodation. c. Document this finding as a consensual reaction. d. Assess the patient's corneal light reflex.

ANS: C Feedback A This is a description of an expected finding—consensual reaction. B Accommodation is not assessed in response to consensual reaction; it tests the function of the oculomotor cranial nerve (CN III). C This is a description of expected consensual reaction. D This item describes a consensual reaction rather than a corneal light reflex

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? a. "I felt faint, like I was going to pass out." b. "I just could not keep my balance when I sat up." c. "It seemed that the room was spinning around." d. "I was afraid that I was going to lose consciousness."

ANS: C Feedback A This is a description of lightheadedness, a form of dizziness. B This is a description of disequilibrium, a form of dizziness. C This is consistent with vertigo because it includes a sensation of motion. D This is a description of syncope, a form of dizziness.

As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings? a. An expected finding b. Koilonychia (spoon nail) c. Clubbing d. Leukonychia

ANS: C Feedback A This is clubbing, which is not an expected finding. B Koilonychia is a thin, depressed nail with the lateral edges turned upward and is associated with anemia. C Clubbing is present when the angle of the nail base exceeds 180 degrees. It is caused by proliferation of the connective tissue resulting in an enlargement of the distal fingers and is most commonly associated with chronic respiratory or cardiovascular disease. D Leukonychia appears as white spots on the nail plate, usually caused by minor trauma or manipulation of the cuticle.

The nurse is taking a health history on a patient who reports frequent headaches with pain in the front of the head, but sometimes felt in the back of the head. Which statement by the patient is most indicative of tension headaches? a. "I usually have nausea and vomiting with my headaches." b. "My whole head is constantly throbbing." c. "It feels like my head is in a vice." d. "The pain is on the left side over my eye, forehead, and cheek."

ANS: C Feedback A This is descriptive of migraines rather than tension headaches. B This is descriptive of migraines rather than tension headaches. C This is descriptive of tension headaches, which is consistent with the rest of the data reported by the patient. D This is consistent with cluster headaches rather than tension headaches.

A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? a. Increased anteroposterior diameter b. Clubbing of the fingers c. Bilateral peripheral edema d. Increased tactile fremitus

ANS: C Feedback A This is seen with lung hyperinflation and may be associated with emphysema. B This is associated with chronic hypoxia and may be associated with cystic fibrosis or chronic obstructive pulmonary disease. C This indicates heart failure; dyspnea occurs because the heart cannot adequately perfuse the lungs. D This occurs when vibrations are enhanced and is associated with consolidation that may occur in pneumonia or tumor.

A nurse uses which technique to assess a patient's peripheral vision? a. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurse's finger as it moves side to side, up and down, and obliquely. b. The nurse covers one of the patient's eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement. c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. d. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.

ANS: C Feedback A This technique tests extraocular muscle symmetry. B This cover-uncover technique is performed when the corneal light reflex is asymmetric. C This is the confrontation test that tests peripheral vision. D This describes the corneal light reflex that tests the symmetry of the eye muscles.

How does a nurse assess movements of the eyes? a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover tes

ANS: C Feedback A This tests the function of cranial nerve I (optic). B This indicates symmetry of eye muscles.C This tests the movement of the eye in all directions, which assesses the functions of the cranial nerves III (oculomotor), IV (abducens), and VI (trochlear). D This is performed after the corneal light reflex is abnormal, indicating asymmetric eye muscles.

A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion? a. As an angioma b. As purpura c. As petechiae d. As ecchymosis

ANS: D Feedback A An angioma is characterized by a small central red area with radiating spider-like legs that blanches with pressure. The lesion of this patient does not blanch. B Purpura is flat, reddish purple, non-blanchable, and greater than 0.5 cm in size. It is caused by infection or a bleeding disorder, not trauma. C Petechiae are tiny, flat, reddish-purple, non-blanchable spots in the skin less than 0.5 cm in diameter and appear as tiny red spots that are pinpoint to pinhead in size. D Ecchymosis is reddish purple in color, nonblanchable and is caused by trauma (being hit with a baseball) to the blood vessel which results in bleeding underneath the skin. The size of the ecchymotic area varies depending on the level of trauma

While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination? a. Flat jugular neck veins b. Red, shiny skin on the legs c. Weak, thready peripheral pulses d. Edema of the feet and ankles

ANS: D Feedback A Flat jugular veins indicate a fluid deficit, which is not associated with dyspnea. B Red, shiny skin on the legs is associated with peripheral arterial disease and is not associated with dyspnea. C Weak, thready peripheral pulses indicate fluid deficit, which is not associated with dyspnea. D This patient may have heart failure. Edema of the feet occurs with right ventricular heart failure. Dyspnea occurs with left ventricular heart failure.

How does a nurse accurately palpate carotid pulses? a. Two fingers of each hand are placed firmly over the right and left temples at the same time. b. One finger is placed gently in the space between the biceps and triceps muscles. c. Two fingers are placed at the thumb side of the forearm at the wrist. d. One finger is placed along the right and then the left medial sternocleidomastoid muscle

ANS: D Feedback A Two fingers of each hand placed firmly over the right and left temples at the same time is the correct procedure for palpating the temporal pulse. B One finger placed gently in the space between the biceps and triceps muscles is the correct procedure for palpating the brachial pulse. C Two fingers placed at the thumb side of the forearm at the wrist is the correct procedure for palpating the radial pulse. D One finger placed along the right and then the left medial sternocleidomastoid muscle is the correct procedure for palpating the carotid pulses, checking each side separately.

How does a nurse recognize a patient's mydriasis? a. The lens of each of the patient's eyes is opaque. b. There is involuntary rhythmical, horizontal movement of the patient's eyes. c. There is a white opaque ring encircling the patient's limbus. d. The patient's pupils are 7 mm and do not constrict.

ANS: D Feedback A An opaque lens is an abnormality that occurs when cataracts are present. B An involuntary rhythmical, horizontal movement of the patient's eyes is a description of nystagmus. C A white opaque ring encircling the patient's limbus is a description of corneal arcus seen in patients older than 60 years of age. D Mydriasis is pupil size greater than 6 mm and the pupil fails to constrict.

A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles and skin that is softened and broken down between the toes? What explanation does the nurse give the patient about the cause of this skin disorder? a. "Your itching is caused by a bacterial infection." b. "Your itching is caused by an allergic reaction." c. "Your itching is caused by a viral infection." d. "Your itching is caused by a fungal infection."

ANS: D Feedback A Bacterial infections such as cellulitis cause redness, warmth, and tenderness, rather than itching. B Allergic reactions such as contact dermatitis cause itching, but they appear as localized erythema, and may also form edema, wheals, scales, or vesicles. C Viral infection such as herpes form grouped vesicles that are painful, rather than itching. D This is a description of tinea pedia, which is caused by a number of dermophyte fungal infections.

. Which finding warrants a referral for additional evaluation? a. Earlobes hanging freely from the base of the pinna b. Ears having painless nodules less than 1 cm in diameter at the helix c. Ears measuring 8 cm in length d. Pinna is 20 degrees lower than the outer canthus of the eye

ANS: D Feedback A Earlobes hanging freely from the base of the pinna is an expected finding. B This is called a Darwin tubercle. It is a normal deviation and may be noted at the helix of the ear. C A length of 8 cm is an expected finding. D The pinna of the ear should align directly with the outer canthus of the eye and be angled no more than 10 degrees from a vertical position

A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient? a. 1+ edema of the feet and ankles bilaterally b. The circumference of the right leg is larger than the left leg c. Patchy petechiae and purpura of the lower extremities d. Cool feet with capillary refill of toes greater than 3 seconds

ANS: D Feedback A Edema of 1+ of the feet and ankles bilaterally is an indication of a venous problem rather than an arterial problem. B When one leg is larger in circumference than the other, it could be due to lymphedema or a deep vein thrombosis. C Petechiae and purpura of the lower extremities indicate a bleeding problem, such as low platelets, rather than an arterial problem. D The pain while walking that is relieved by rest is called intermittent claudication and is an indication of arterial insufficiency. Cool feet and prolonged capillary refill also occur due to arterial insufficiency

During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the patient's skin, what finding will confirm the rash? a. Elevated, firm, well-defined lesions less than 1 cm in diameter b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter c. Elevated, fluid-filled lesions less than 1 cm in diameter d. Flat, well-defined, small lesions less than 1 cm in diameter

ANS: D Feedback A Elevated, firm, well-defined lesions less than 1 cm in diameter is a description of a papule. B Depressed, firm, or scaly, rough lesions greater than 1 cm in circumference is an incorrect description. C Elevated, fluid-filled lesions less than 1 cm in diameter is a description of a vesicle. D Flat, well-defined, small lesions less than 1 cm in diameter is a description of a macule

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? a. Increased fremitus over the left chest b. Tracheal deviation to the left side c. Hyporesonant percussion tones over the left chest d. Distant to absent breath sounds over the left chest

ANS: D Feedback A Increased fremitus occurs over lung consolidation as in lobar pneumonia or tumor. B If this patient had a tension pneumothorax, the trachea would deviate to the right. C Hyperresonant percussion tones are heard when the lung is overinflated as in emphysema. D The air separating the lung from the chest where the nurse is auscultating creates distant to absent breath sounds.

During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination? a. Increased tactile fremitus b. Inspiratory and expiratory wheezing c. Tracheal deviation d. An increased anteroposterior diameter

ANS: D Feedback A Increased tactile fremitus occurs when vibrations are enhanced and is associated with consolidation that may occur in pneumonia or tumor. B Inspiratory and expiratory wheezing is associated with asthma. C Tracheal deviation is associated with tension pneumothorax. D An increased anteroposterior diameter is consistent with emphysema

How does a nurse recognize normal accommodation? a. The patient has peripheral vision of 90 degrees left and right. b. The patient's eyes move up and down, side to side, and obliquely. c. The right pupil constricts when a light is shown in the left pupil. d. The patient's pupils dilate when looking toward a distant object.

ANS: D Feedback A Normally a patient has 90 degrees peripheral vision temporally, but only 60 degrees nasally. B This is an expected finding, but is not a test for accommodation. It is a test of extraocular muscle function in the six cardinal fields of gaze. C This is an expected finding for consensual reaction, rather than accommodation. D This is an indication of accommodation.

Wearing gloves, the nurse grasps the patient's tongue with a gauze pad and palpates a small, firm nodule on the left side of the tongue. Based upon this finding, what is the nurse's appropriate response? a. Document that the patient's tongue is normal on palpation. b. Inspect the left submandibular salivary glands for redness. c. Ask the patient to move the tongue in all directions. d. Palpate cervical and submental lymph nodes for enlargement.

ANS: D Feedback A The nodule is not an expected finding. B The salivary glands are not affected by a nodule of the tongue. C This assesses the hypoglossal cranial nerve or movement of the tongue, which is not related to the nodule found. D The nodules may indicate a malignancy of the tongue, which may also cause enlarged cervical or submental lymph nodes.

. How is the first heart sound (S1) created? a. Pulmonic and tricuspid valves close. b. Mitral and aortic valves close. c. Aortic and pulmonic valves close. d. Mitral and tricuspid valves close.

ANS: D Feedback A The pulmonic and tricuspid valves are the valves of the right side of the heart, and they do not close simultaneously in the cardiac cycle. B The mitral and aortic valves are the valves of the left side of the heart, and they do not close simultaneously in the cardiac cycle. C The aortic and pulmonic valves are the semilunar valves that create the second heart sound. D The first heart sound (S1) is made by the closing of the mitral (M1) and tricuspid (T1) valves

When performing a skin assessment of an adult patient, the nurse expects what finding? a. Reddened area does not blanch when gentle pressure is applied b. Indentation of the finger remains in the skin after palpation c. Flaking or scaling of the skin d. Return of skin to its original position when pinched up slightly

ANS: D Feedback A This is an indication of a stage I pressure ulcer. B This is a description of edema. C This may be an indication of dry skin, systemic disease, or nutritional deficiency. D This is an assessment of skin turgor; skin should return to its original position.

The nurse is taking a health history on a patient who reports frequent stabbing headaches occurring once a day lasting about an hour. Which statement by the patient is most indicative of cluster headaches? a. "I usually have nausea and vomiting with my headaches." b. "My whole head is constantly throbbing." c. "It feels like my head is in a vice." d. "The pain is on the left side over my eye, forehead, and cheek."

ANS: D Feedback A This is descriptive of migraines rather than cluster headaches. B This is descriptive of migraines rather than cluster headaches. C This is descriptive of tension rather than cluster headaches. D This description is consistent with cluster headaches.

During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what does the nurse expect for during the examination of this patient's mouth? a. Cracks and erythema in the corners of the mouth b. Slightly rough papillae on the dorsal surface of the tongue c. Smooth or beefy, red-colored, edematous tongue d. Painless, nonhealing mouth ulcers

ANS: D Feedback A This may be caused by vitamin B deficiencies. B These are an expected finding on the tongue. C This may be an indication of anemia. D This may indicate oral cancer.

On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding? a. As an indication of a type of anemia b. As a hordeolum or sty c. As jaundice d. As an expected racial variation

ANS: D Feedback A This may cause a pale conjunctiva. B This is an acute infection originating in the sebaceous gland of the eyelid. C Jaundice is a yellow color of the sclera associated with liver or gallbladder disease. D This as an expected racial variation.

. A toddler patient has a small, slightly raised bright red area on the trunk. The child's mother reports that the lesion has been present since birth and has become a little larger. What type of lesion does the nurse suspect? a. Vascular nevi b. Purpura c. Ecchymosis d. Cherry hemangioma

ANS: D Feedback A Vascular nevi is a type of angioma that involves the capillaries within the skin producing an irregular macular patch that can vary from light red to dark red to purple in color. B Purpura is a flat, reddish purple, nonblanchable discoloration in the skin greater than 0.5 cm in diameter. C Ecchymosis is a reddish purple, nonblanchable spot of variable size. D Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age.

Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult? a. In the lower lobes b. Over the trachea c. In the apices of the lungs d. Near the sternal border .

ANS: D Feedback A Vesicular breath sounds are normally heard in the lower lobes. B Bronchial sounds are normally heard over the trachea. C Vesicular breath sounds are normally heard in the apices of the lungs. D Bronchovesicular breath sounds are normally heard over the central area of the anterior thorax around the sternal border

During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? a. Virus b. Allergy c. Fungus d. Bacteria

ANS: D Feedback A A virus usually produces a nonproductive cough. B An allergy usually produces clear sputum. C A fungus usually produces few symptoms. The sputum used to diagnose the fungus is obtained from tracheal aspiration rather than the patient coughing up the sputum. D Bacteria usually produce sputum that is yellow or green in color.

. Which question will give the nurse additional information about the nature of a patient's dyspnea? a. "How often do you see the physician?" b. "How has this condition affected your day-to-day activities?" c. "Do you have a cough that occurs with the dyspnea?" d. "Does your heart rate increase when you are short of breath?"

B A This question does not relate specifically to the patient's dyspnea. B This question provides data about the severity of the dyspnea and what actions the patient has taken to cope with the dyspnea on a daily basis. C This question provides data, but does not give additional facts about the patient's dyspnea. D This is a closed-ended question that does not collect additional data about this episode of dyspnea.

To assess jaw movement of an adult patient, the nurse uses which technique? a. Asking the patient to open the mouth and then passively moving the patient's open jaw from side to side b. Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth c. Asking the patient to open the mouth and to resist the nurse's attempt to close the mouth d. Using the pads of all fingers to feel along the mandible for tenderness and nodules

B Feedback A The patient's jaw movement should be active, not passive. B This is the correct technique for palpating the jaw. C This technique assesses strength of the jaw, which is not typically evaluated. D Palpating under the middle of the mandible may reveal the submental lymph node.

On inspection, a nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate? a. Increased vocal fremitus on palpation b. Dull tones heard on percussion c. Decreased breath sounds on auscultation d. Complaint of sharp chest pain on inspiration

C Feedback A Increased fremitus occurs when the vibrations feel enhanced. This is found when lung tissues are congested or consolidated, which may occur in patients who have pneumonia or a tumor. B Dull tones may be heard in patients with pneumonia, pleural effusion, or atelectasis. C The equal anteroposterior and lateral diameters of the chest indicate air trapping from enlarged or destroyed alveoli. This air trapping causes decreased to absent breath sounds on auscultation. D Complaint of sharp chest pain on inspiration is pleuritic chest pain associated with pleural lining irritation and may occur in a patient with pleurisy or pneumonia.

A patient reports the mole on the scalp has started itching and it bleeds when scratching it. What other finding is a danger sign for pigmented skin lesions? a. Symmetry of the lesion b. Rounded border c. Color variation d. Size less than 6 mm wide ANS: C

C Feedback A Symmetry is an expected finding for moles. Asymmetric lesions are an early sign of malignant melanoma. B A rounded border is an expected finding. A border that is poorly defined or irregular is an early sign of malignant melanoma. C Uneven, variegated color is an early sign of malignant melanoma. D A size of less than 6 mm wide is an expected finding. A lesion greater than 6 mm is an early sign of malignant melanoma.

Which finding on assessment of a patient's eyes should the nurse document as abnormal? a. An Asian American patient with an upward slant to the palpebral fissure b. A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris c. An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus d. An American Indian patient whose pupillary diameters are 5 mm bilaterally

b Feedback A An Asian American patient with an upward slant to the palpebral fissure has an expected racial variation. B A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris has eyeball protrusion beyond the supraorbital ridge, which indicates exophthalmos caused by hyperthyroidism. C An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus has an expected racial variation. D An American Indian whose pupils are 5 mm bilaterally is an expected finding.