Health Assessment Exam #2

A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor. Which of the following findings should the nurse expect on performing pectoriloquy?

"1-2-3" is heard clearly.

A client is admitted for treatment of hypothyroidism. What should the nurse expect to assess in this client? Select all that apply.

-Periorbital edema -Thin Layer Eyebrow -Dry, Coarse, and Sparse hair -Puffy dull face with dry skin

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

Where is Erb's point located?

3rd left rib space

Which of the following clients is most likely to be diagnosed with migraine headaches?

A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?

Ask the client if she has recently exerted herself.

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?

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

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?

Bacterial infection

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

Blood pressure

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?

Bronchitis

The nurse assesses a client's neck as shown. What is the nurse assessing?

Carotid artery

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

Chronic Bronchitis

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?

Chronic obstructive lung disease

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

Chronic obstructive pulmonary disease

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

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

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Compressing the arteries bilaterally

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

Cup of water

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern?

Decreased cardiac output

A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

What activity is known to aggravate a tension headache?

Driving

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

Dullness

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply.

Eat foods low in sodium. Walk for at least 30 minutes/day. Use relaxation techniques to manage stress.

T/F: A client with lobar pneumonia would have muffled and indistinct spoken voice sounds.

False

A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal?

Fatigue, cold intolerance, and constipation.

After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?

Female gender

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

Fifth intercostal space, left midclavicular line

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

Funnel chest

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

Grade 5

A client, scheduled for pacemaker insertion, does not understand why the device is needed. Where should the nurse identify the location of the sinoatrial node on the diagram when instructing the client about the surgery?

Identify the SA node

A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase 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

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?

Just below the cricoid cartilage

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client?

Low-fat, low-cholesterol meals

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?

Lymphatic

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?

Mask-like expression

A nurse expects to find which abnormal heart sound in a client diagnosed with mitral valve prolapse?

Midsystolic click

A client is diagnosed with mitral valve stenosis. Using the diagram, where should the nurse identify this valve when teaching the client about the health problem?

Mitral valve = Bicuspid Valve

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

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?

Nodularity

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

Notify the healthcare provider immediately.

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

During a health history, a client reports complaints of headaches. What would lead the nurse to suspect that the client is experiencing cluster headaches?

Pain radiating from eye to temporal region

What are the 5 P's to assess circulation

Pain, Pallor, Pulselessness, Paresthesia, Paralysis

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition?

Place the bell of the stethoscope over the apex with client on left side.

The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique?

Place the diaphragm on the client's posterior chest wall.

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

Pneumonia

The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?

Pulmonary edema

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Referral for further assessment of thyroid function

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

S2

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.

Which of the following is consistent with good percussion technique?

Strike the pleximeter over the distal interphalangeal joint.

The results of a client's ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis?

Sudden onset of dyspnea

The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?

The client may be experiencing symptoms of heart failure.

A client complains of palpitations and a feeling of anxiety. Which of the following would be most appropriate for the nurse to keep in mind?

The heart is attempting to increase cardiac output.

The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?

The pattern is expected with this condition

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones

A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?

Trigeminal neuralgia

During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following?

Trigeminal neuralgia

Reduction of Risk Potential for Hyperthyroidism (S/S)

Warm, moist, soft, and velvety skin to the touch; thin and fine hair; alopecia; vitiligo hyperpigmentation (localized or general); bruit when auscultating, retracted eyelids; (fine & rapid) postural tremors Suggested when food intake is relatively high, but weight loss is occurring. Hyperthyroidism increases the risk of osteoporosis Older adults present with fatigue, weight loss, and tachycardia, heat intolerance, sweating, hyperreflexia, atrial fibrillation, weakness, constipation, dry skin, and cold intolerance

The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?

Within triangle closest to the trachea

In a healthy adult, what is the expected respiratory rate? a. 4-14 breaths per minute b. 14-16 breaths per minute c. 12-20 breaths per minute d. 26-40 breaths per minute

a. 12-20 breaths per minute

The nurse is caring for an adult client who has symptoms of thyroid dysfunction. Which of the following assessments should be included? a. Auscultation of the thyroid b. Auscultation of the lungs c. Breast assessment d. Palpation of the lymph nodes

a. Auscultation of the thyroid

The apex of each lung is located at the

area slightly above the clavicle.

Reduction of Risk Potential for Breast Variations

one breast is usually bigger than the other; look for changes in shape, nipple discharge, pain, dimpling/ retracting, asymmetric alignment, any skin changes, any sudden enlargement, and assess for any lumps/masses

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

pneumonia.

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

repeat the phrase "ninety-nine."

A client has engorged jugular veins. What should this finding suggest to the nurse?

right atrial pressure

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension

The nurse would expect to assess which symptoms in a client complaining of migraine headaches? Select all the apply.

throbbing, photophobia, recurrent

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?

Graves' disease

What is the most common type of hyperthyroidism?

Graves' disease

The nurse is assessing an adult client who reports hair loss. The client has been diagnosed with hyperthyroidism. Which of the following hair characteristics should the nurse expect to find in this client? a. Fine texture hair b. Coarse texture hair c. Weight gain d. Constipation

a. Fine texture hair

The nurse is conducting a workshop on the measurement of jugular venous pulsation. As part of instruction, the nurse tells the students to make sure that they can distinguish between the jugular venous pulsation and carotid pulse. Which of the following characteristics is typical of the carotid pulse?

palpable

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

Flat neck veins

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

The nurse is providing education to a patient about how to perform a self-breast exam. When is the best time to perform a breast exam? a. 5-7 days after the onset of menstruation b. 6-8 days before the onset of menstruation c. The day menstruation starts d. Two weeks after the onset of menstruation

a. 5-7 days after the onset of menstruation

The nurse is assessing an adult client who has presented with palpitations and shortness of breath. The client has been diagnosed with atrial fibrillation. Which of the following is the most likely finding upon auscultation of the client's heart? a. An irregularly irregular rhythm a. A rapid regular rhythm b. A mid-systolic click c. Bigeminy

a. An irregularly irregular rhythm

The nurse is evaluating a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). On physical examination of the thorax, which of the following is an expected finding? a. Increased AP diameter b. Decreased AP diameter c. No change in the AP diameter d. Pectus excavatum

a. Increased AP diameter

The nurse auscultates a client's thorax at the first & second intercostal spaces (ICS) anteriorly and between the scapulae posteriorly. Which of the following is true about this location? a. It is the expected location of broncho-vesicular breath sounds. b. It is the location of the lower border of the lungs. c. It is the location of the trachea bifurcation. d. It is the location of the diaphragm.

a. It is the expected location of broncho-vesicular breath sounds.

While conducting a cardiovascular assessment, the nurse is aware that which of the following is produced by closure of the mitral valve? a. S1 b. S2 c. S3 d. S4

a. S1

The nurse is aware that which of the following is produced by closure of the aortic valve? a. S2 b. S1 c. S3 d. S4

a. S2

Which of the following occurs after the mitral valve opens and is related to rapid ventricular filling? a. S3 b. S2 c. S1 d. S4

a. S3

The nurse should be aware that which of the following is true regarding the sternal angle anteriorly and the T4 spinous process posteriorly? a. This is the location of the trachea bifurcation. b. This is the location of the lower lung border. c. This is the location of tracheal breath sounds. d. This is the location with the loudest vesicular breath sounds

a. This is the location of the trachea bifurcation.

The nurse is caring for a client who has found a lump in her right breast. The client reports that it first appeared 3 months ago, it changes with her menstrual cycle, and it is tender to the touch. She denies a family history of breast cancer. Upon physical exam, the nurse finds no dimpling or retraction present, but a round, 2-cm, freely mobile, tender, circumscribed, firm, somewhat elastic mass is palpated. Which of the following is the most likely diagnosis? a. Fibroadenoma b. Cyst c. Breast cancer d. Mastitis

b. Cyst

The nurse is caring for a client who was admitted with an asthma exacerbation. The initial assessment found loud wheezing. Before a treatment is provided, the nurse notices that the wheezing has become quieter. What should the nurse's next action be? a. Tell the patient they can go home because they are getting better. b. Notify the provider that the patient needs to be seen immediately. c. Initiate the Code Blue protocol. d. .Return in a few minutes with medication.

b. Notify the provider that the patient needs to be seen immediately.

The nurse is assessing an adult client's cardiovascular system. The client has a history of congestive heart failure (CHF), hypertension (HTN), and hyperlipidemia (HLD). Which of the following is an expected finding for this client? a. PMI in the 5th ICS, midclavicular line b. PMI in the 5th ICS, anterior axillary line c. PMI in the 3rd ICS, midclavicular line d. PMI in the 8th ICS, anterior axillary line

b. PMI in the 5th ICS, anterior axillary line

The nurse is performing posterior palpation of the thyroid gland. Which of the following actions by the nurse requires re-education? a. Asking the client to tip their head to the side. b. Placing index fingers above the client's cricoid cartilage. c. Palpating between the sternocleidomastoid muscle & the trachea. d. Moving fingers laterally to palpate for thyroid lobes.

b. Placing index fingers above the client's cricoid cartilage.

When auscultating a client with COPD, which of the following may the nurse expect to hear? a. Stridor b. Prolonged expiratory phase c. Late inspiratory crackles d. Pleural rub

b. Prolonged expiratory phase

When auscultating a client's lungs, which of the following findings may indicate a pneumothorax? a. Wheezes on the opposite side. b. Rhonchi on the affected side. c. Absent breath sounds on the affected side. d. Resonance on the opposite side.

c. Absent breath sounds on the affected side.

The nurse is assessing an adult client who has presented with shortness of breath. The client has been diagnosed with right-sided heart failure. Which of the following findings is expected in this client? a. Flattened jugular veins b. JVP as expected c. Elevated JVP d. Decreased JVP

c. Elevated JVP

The nurse should be aware that which of the following is true regarding the 6th rib at the midclavicular line & the 8th rib at the midaxillary line? a. This is the location of the apex of the lungs. b. This is the location of the trachea bifurcation. c. This is the location, anteriorly, of the lower border of the lungs. d. This is the point of maximal impulse (PMI).

c. This is the location, anteriorly, of the lower border of the lungs.

While auscultating for mitral valvular sounds, the nurse should place the stethoscope at which of the following locations? a. Right of sternum, 2nd ICS b. Left of sternum, 2nd ICS c. Left mid-clavicular line, 4th ICS d. Left, mid-clavicular line, 5th ICS

d. Left, mid-clavicular line, 5th ICS

The nurse should be aware that which of the following is true regarding the T10 spinous process? a. This is the location of broncho-vesicular breath sounds. b. This is the location, anteriorly, of the lower border of the lung. c. This is the location of the loudest fremitus. d. This is the location, posteriorly, of the lower border of the lung.

d. This is the location, posteriorly, of the lower border of the lung.

A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply.

hyoid bone cricoid cartilage

After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?

hyperresonance