Health Assessment Exam 2 Study Questions plus SATA

the nurse is preparing to perform a cardiac assessment on a client. rank the assessment steps in the order in which they will occur. percussion of the client's chest palpation of the precordium and pulses inspection of the client's head and beck, chest, abdomen, and extremities auscultation of the client's heart, apical pulse, and carotid arteries

1. inspection 2. palpation 3. percussion 4. auscultation

the popliteal artery can be palpated at the 1. knee 2. groin 3. foot 4. ankle

1. knee

what is the most accurate technique for detecting a venous thrombosis at the bedside? 1. measure the thigh circumference to detect an increase from the baseline 2. dorsiflex the calf and notice if the patient complains of pain 3. elevate one leg above the level of the heart to determine if the veins empty 4. palpate the pulses distal to the areas of the suspected thrombosis

1. measure the thigh to detect an increase from the baseline

during a physical examination, the nurse is unable to feel the patient's thyroid gland with palpation from an anterior approach. what is the appropriate action of the nurse at this time? 1. recognize that this is an expected finding 2. auscultate the thyroid area 3. palpate the thyroid using a posterior approach 4. refer the patient for follow-up with an endocrinologist

1. recognize that this is an expected finding

a client who works in a manufacturing plant is attending a teaching session on plant safety. which of the following would be an important risk prevention measure to teach regarding hearing? 1. wearing ear guards whenever inside the plant 2. minimizing the amount of noise exposure to 3 hours a day 3. taking a 10 min break every 2 hours 4. cleaning ears regularly to prevent ear infections

1. wearing ear guards whenever inside the plant

4. A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document these findings? 1. "Tonsils yellow and edematous." 2. "Enlarged tonsils 4+ with yellow exudate." 3. "Strep infection to tonsils with 3+ swelling." 4. "1+ edema of tonsils with pus."

2. "Enlarged tonsils 4+ with yellow exudate."

a RN is assessing a client's tonsils who complains of throat pain. she noticed that the tonsils are halfway between the pillars and uvula with white patches on them. which grading should the nurse document this enlargement of tonsils? 1. 1+ 2. 2+ 3. 3+ 4. 4+

2. 2+

the nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. which location should the nurse assess next? 1. 5th intercostal space, left midclavicular line 2. 2nd intercostal space, left sternal border 3. 2rd intercostal space, left sternal border 4. 4th left intercostal space

2. 2nd intercostal space, left sternal border

which of the following will take over if the SA node failed to fire an effective electrical signal in the heart? 1. purkinje fibers 2. AV node 3. right bundle of his 4. left bundle of his

2. AV node

9. A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position.

2. Ask the patient to cough then repeat the auscultation.

1. A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. Green 2. Clear 3. Yellow 4. Pink tinged

2. Clear

11. What are the characteristics of lymph nodes in patients who have an acute infection? 1. They are enlarged and tender. 2. They are round, rubbery, and mobile. 3. They are hard, fixed, and painless. 4. They are soft, mobile, and painless.

1. They are enlarged and tender.

7. Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar

1. Vesicular

5. A patient has a herpes lesion on her vulva. While examining her, the nurse should take which measures? 1. Wear examination gloves while in contact with the genitalia. 2. Place the patient in an isolation room. 3. Wash the genitalia with alcohol or povidone-iodine (Betadine) before the examination. 4. Inspect the genitalia only; reschedule the patient for a full examination after the lesion has healed.

1. Wear examination gloves while in contact with the genitalia.

8. Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub

1. Wheeze

a patient describes a recent onset of frequent and severe unilateral headaches that last about 1 hr. based on these symptoms, the nurse suspects which type of headache? 1. cluster 2. migraine 3. tension 4. sinus

1. cluster

the nurse is assessing the client's cardiovascular system. which techniques are appropriate for the nurse to use during this assessment? SATA. 1. examining the client's legs and noting that the client's hair is evenly distributed 2. continuing the exam when the client complains of discomfort when lying flat 3. auscultating the apical impulse at the fifth intercostal space on the left midclavicular line 4. examining the client's hands and fingers and noticed the presence of clubbing 5. palpating the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate

1. examining the client's legs and noting that the client's hair is evenly distributed 3. auscultating the apical impulse at the fifth intercostal space on the left midclavicular line 4. examining the client's hands and fingers and noticed the presence of clubbing

what are the signs and symptoms of left-sided heart failure? SATA. 1. fatigue 2. orthopnea 3. pink frothy sputum 4. jugular vein distention 5. lung sounds - crackles

1. fatigue 2. orthopnea 3. pink frothy sputum 5. lung sounds - crackles

the nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease? the nurse should instruct the client to reduce her risk factors by 1. getting regular exercise 2. drinking large quantities of milk 3. resting frequently 4. eating a high-protein diet

1. getting regular exercise

when obtaining a cardiovascular health history on a patient, the nurse should ask the patient which questions? SATA. 1. have you ever been treated for any cardiovascular disease? 2. have you had any weight changes? 3. are you able to your activities of daily living? 4. do you have any body aches? 5. do you know your cholesterol and triglyceride levels?

1. have you ever been treated for any cardiovascular disease? 2. have you had any weight changes? 3. are you able to your activities of daily living? 5. do you know your cholesterol and triglyceride levels?

which of the following statements made by the nursing student about jugular vein distention indicates further education is needed? 1. i expect to see jugular vein distention with left side heart failure 2. i expect to see jugular vein distention with right side heart failure 3. jugular vein distention is a sign of increased central venous pressure 4. jugular vein distention should be best assessed from the right internal jugular vein

1. i expect to see jugular vein distention with left side heart failure

the nurse positions her hands for a thyroid examination with a posterior approach. once she has identified landmarks and her hands are in place, she advises the patient to : 1. cough 2. say "ah" 3. swallow 4. turn her head from side to side

3. swallow

which finding does the nurse expect during auscultation of the heart? 1. a low-pitched blowing sound is heard over the apex of the heart 2. a high-pitched vibration is heard over the base of the heart 3. the S1 heart sound is louder at the apex of the heart 4. the S3 heart sound sounds like "Ken-tuck-y"

3. the S1 heart sound is louder at the apex of the heart

a registered nurse is listening to a client's heart sound. she hears a murmur and she knows the mechanism of a murmur is 1. pericarditis 2. emphysema 3. turbulent blood flow 4. cardiac tamponade

3. turbulent blood flow

12. Which technique is used for palpating lymph nodes? 1. Apply firm pressure over the nodes with the pads of the fingers. 2. Apply gentle pressure over the nodes with the tips of the fingers. 3. Apply firm pressure anterior to the nodes with the tips of the fingers. 4. Apply gentle pressure over the nodes with the pads of the fingers.

4. Apply gentle pressure over the nodes with the pads of the fingers.

10. 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? 1. Increased fremitus over the left chest 2. Tracheal deviation to the left side 3. Crepitus on the left chest during palpation 4. Distant to absent breath sounds over the left chest

4. Distant to absent breath sounds over the left chest

3. Which data collected from the history of a 32-year-old female patient should be followed with a symptom analysis? 1. Has never had a mammogram. 2. Experiences light to moderate bleeding during the menstrual cycle. 3. Periods began at age 12; has never been pregnant. 4. Has pelvic pain and vaginal discharge.

4. Has pelvic pain and vaginal discharge.

a client with chronic bronchitis is admitted to the hospital. the nurse inspects the client while assessing the client's respiratory system. which assessment finding is expected? a. dry cough b. decreased respiratory rate c. fever d. use of accessory muscles

d. use of accessory muscles

4. On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub

1. Rhonchi

7. Which finding is expected during a rectal exam? 1. The rectal wall is smooth. 2. Severe pain is reported when the finger is introduced through the anus. 3. Hard stool is present in the rectum. 4. The anus is surrounded by white flat lesions.

1. The rectal wall is smooth.

5. A man seeks treatment for "recent breast enlargement." On examination the nurse notes bilateral enlargement of the breasts. Which question asked by the nurse is most appropriate based on this finding? 1. "What medications are you currently taking?" 2. "Have you recently been lifting weights?" 3. "Did your mother have large breasts?" 4. "Have you ever had cancer?"

1. "What medications are you currently taking?"

5. A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the tongue. What additional data does the nurse specifically collect about this patient? 1. Alcohol and tobacco use 2. Date of his last dental examination 3. Use of dentures 4. A history of pyorrhea

1. Alcohol and tobacco use

2. A 22-year-old white male comes to the emergency department with a concern about a mass in his testicle. In addition to his age and race, which fact is a known risk factor for testicular cancer? 1. He had an undescended testicle at birth. 2. His mother had breast cancer. 3. He was treated for gonorrhea 18 months ago. 4. He had a hydrocele during infancy.

1. He had an undescended testicle at birth.

1. Which finding does the nurse recognize as abnormal when examining a male patient? 1. Testes are palpable and firm within the scrotal sac bilaterally 2. Discharge observed from the penis when the glans is compressed 3. Foreskin lies loosely over the penis 4. Glans a lighter skin tone than the rest of the penis

2. Discharge observed from the penis when the glans is compressed

4. A 19-year-old college student comes to the student health center because she discovered a small, nontender, firm, rubbery lump in her right breast. What is the most common cause of breast lumps in women her age? 1. Breast cancer 2. Fibroadenoma 3. Ductal ectasia 4. Breast abscess

2. Fibroadenoma

protrusion of the eyeball (exophthalmos) with a glaring appearance is usually associated with which illness? 1. diabetes 2. Graves disease 3. cancer of the pancreas 4. chronic renal failure

2. Graves disease

10. A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem? 1. Gallbladder disease 2. Hemorrhoids 3. Rectal polyps 4. Upper intestinal bleeding

2. Hemorrhoids

when examining and documenting findings associated with the eyes, nurses typically follow the assessment model noted below. 1. HEENT 2. PERRLA 3. PEARL 4. AACN

2. PERRLA

4. While taking the health history of a 23-year-old female patient, the nurse considers risk factors for STD. Which data from the patient suggest a need for patient education? 1. She has been in a monogamous sexual relationship for 2 years; she uses a condom to prevent pregnancy. 2. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy. 3. She has a Pap test each year, and the results have been negative. 4. She uses oral contraceptives to prevent pregnancy.

2. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy.

8. The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is considered abnormal? 1. Presence of cerumen 2. Yellow color to the tympanic membrane 3. Presence of a cone of light 4. Shiny, translucent tympanic membrane

2. Yellow color to the tympanic membrane

which conduction would a RN expect to last longer when assessing hearing with a tuning fork? 1. bone conduction 2. air conduction 3. cartilage conduction 4. pinna conduction

2. air conduction

where is the maximum impact of the heart located? 1. pulmonic valve 2. apical pulse 3. Erb's point 4. aortic valve

2. apical pulse

a patient complains of pain in the calf when walking. which question should the nurse ask for further data? 1. does your calf also swell when this pain occur? 2. does the pain go away when you stop walking? 3. do you become short of breath when you're walking? 4. do you feel dizzy when the pain occurs?

2. does the pain go away when you stop walking?

which of the following is NOT a prostate cancer risk factor? 1. African American race 2. history of CHF 3. age older than 65 4. high dairy intake

2. history of CHF

which one of the following is NOT associated with black tarry stools? 1. excessive iron 2. obstructive jaundice 3. bismuth ingestion 4. upper GI bleeding

2. obstructive jaundice

the nurse is preparing to examine a client's internal ear. which equipment would be necessary? 1. measuring tape 2. otoscope 3. tuning fork 4. watch with a second hand

2. otoscope

where does a nurse palpate the posterior tibial pulse? 1. behind the knee in the popliteal fossa 2. the inner aspect of the ankle below and slightly behind the medial malleolus 3. over the dorsum of the foot between the tendons of the first and second toes 4. the outer side of the ankle below and slightly behind the lateral malleolus

2. the inner aspect of the ankle below and slightly behind the medial malleolus

if the clinician documents that the tonsils are graded as 3+ in size, it means: 1. the tonsil are visible 2. the tonsils are nearly touching the uvula 3. the tonsils are halfways between tonsillar pillars and uvula 4. the tonsils are touching one another

2. the tonsils are nearly touching the uvula

an RN is assessing a client's tonsils who complains of throat pain. she noticed that the tonsils are halfway between the pillars and uvula with white patches on them. the client reports fever and chills. which condition would the nurse expect this client to be diagnosed with? 1. strep throat 2. tonsilitis 3. herpes simplex 4. candidiasis

2. tonsillitis

when a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. what were you doing when the pain first occurred? 2. what does the pain feel like? 3. do you have shortness of breath? 4. has anyone in your family ever had a similar pain?

2. what does the pain feel like?

7. Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss? 1. "I watch TV in the evenings with my wife and children." 2. "When I was younger, I wore an earring." 3. "My primary hobby is carpentry work." 4. "I have been an accountant for 16 years for an insurance agency."

3. "My primary hobby is carpentry work."

10. How does the nurse assess a patient's consensual reaction? 1. By touching the cornea with a small piece of sterile cotton and observing the change in the pupil size 2. By observing the patient's pupil size when the patient looks at an object 2 to 3 feet away and then looks at an object 6 to 8 inches away 3. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye 4. By covering one eye with a card and observing the pupillary reaction when the card is removed

3. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye

5. A nurse finds the patient's AP diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation 4. Complaint of sharp chest pain on inspiration

3. Decreased breath sounds on auscultation

how does a nurse determine jugular vein pulsations? 1. Raises the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; inspects for jugular vein pulsations during the cough

3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle

9. During an examination, the nurse palpates the Skene glands. Which technique best describes this process? 1. Exerting pressure over the clitoris, slide the finger downward (posteriorly) toward the vaginal opening. 2. Palpate the fourchette and slide the finger forward (anteriorly) toward the vaginal opening. 3. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening. 4. Grasp the labia majora between the index finger and thumb and milk the labia outward.

3. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening.

3. A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion and rhonchi on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe

3. Fever and tachypnea with crackles over the right lower lobe

1. Which finding is considered abnormal when conducting a breast examination on a 68-year-old woman? 1. Dark pink areola 2. Pendulous breasts 3. Serous nipple drainage 4. Granular texture

3. Serous nipple drainage

3. What is the reason for palpating axillary lymph nodes during a clinical breast examination? 1. Axillary nodes fluctuate during the month in response to the menstrual cycle. 2. Axillary node tenderness is the most common initial symptom of breast cancer. 3. The lymph network in the breast primarily drains toward the axillary lymph nodes. 4. This is a matter of convenience because of the close proximity of the axillae to the breasts.

3. The lymph network in the breast primarily drains toward the axillary lymph nodes.

6. To inspect the glans penis of the uncircumcised male, the nurse retracts the foreskin. After inspection, she is unable to replace the foreskin over the glans. The nurse recognizes that this situation could potentially lead to which complication? 1. Decreased sperm production 2. Urinary tract infection 3. Tissue necrosis of the penis 4. Testicular cancer

3. Tissue necrosis of the penis

8. The nurse recognizes which symptom as commonly associated with prostate enlargement? 1. Constipation 2. Rectal bleeding 3. Weak urinary stream 4. Penile discharge

3. Weak urinary stream

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? 1. an opening snap 2. a diastolic murmur 3. a systolic murmur 4. a pericardial friction rub

3. a systolic murmur

a client performs the test for distant visual acuity and scores 20/50. how should the nurse most accurately interpret this finding? 1. client can read the 20/50 line correctly and two other letters on the line above 2. client did not wear his glasses for this test and therefore it is not accurate 3. at 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. 4. when 50 feet from the chart, the client can see better than a person standing at 20 feet.

3. at 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

a nurse auscultates a client's heart sounds and obtains a rate of 56 bpm. how should this rate be documented by the nurse? 1. tachycardia 2. sinus rhythm 3. bradycardia 4. apnea

3. bradycardia

which of the following describes normal health lymph nodes? 1. general hard to touch with heat 2. it is normal for patients to report tenderness while palpating lymph nodes 3. generally impalpable; if palpable, lymph nodes should be soft and mobile 4. lymph nodes should always be visible

3. generally impalpable; if palpable, lymph nodes should be soft and mobile

a RN assessed a client's ears and noticed some redness and swelling on the tympanic membrane in the left ear. the client states "my left ear has been hurting me." which of the following would be the most appropriate diagnosis? 1. tympanic membrane retraction 2. tympanosclerosis 3. otitis media 4. ruptured eardrum

3. otitis media

while inspecting the legs of a male patient, the nurse notices that the skin is shiny and taut with little hair growth. which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. pitting edema of one or both feet or legs 2. increased circumference in the thighs bilaterally 3. pale, cool legs with diminished-to-absent dorsalis pedis pulses 4. pain when legs are dependent that is relieved when legs are elevated

3. pale, cool legs with diminished-to-absent dorsalis pedis pulses

a nurse is unable to palpate a client's radial and ulnar pulses? which of the following would the nurse do next? 1. auscultate the apical pulse 2. refer the client for medical follow-up 3. palpate the brachial pulse 4. document the finding

3. palpate the brachial pulse

a client that reports pain in the legs that begins with walking but is relieved by rest. which condition should the nurse assess the client for? 1. obstruction in the femoral artery 2. diabetes mellitus 3. peripheral arterial problems 4. calcium deficiency

3. peripheral arterial problems

drooping of one or both eyelids is called 1. accommodation 2. entropian 3. ptosis 4. ectropion

3. ptosis

what is the most important lifestyle changes a client can make to improve cardiovascular health? 1. living a more sedentary lifestyle 2. getting less exercise and more rest 3. quitting smoking 4. eating a diet high in fat

3. quitting smoking

during the inspection of a 5-year-old girl's reproductive system, the nurse identified small lacerations and bruises of the labia majora and minora. what does this finding suggest to the nurse? 1. pediculosis pubis 2. masculinization 3. sexual abuse 4. sexual transmitted infection

3. sexual abuse

each patient has had consistent blood pressure readings during the last three clinic visits. which patient has a blood pressure consistent with expected findings? 1. Ms. J, whose blood pressure has been 140/90 2. Mr. Q, whose blood pressure has been 130/76 3. Ms. Y, whose blood pressure has been 120/80 4. Mr. P, whose blood pressure has been 110/78

4. Mr. P, whose blood pressure has been 110/78

2. During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's race 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate of 20 breaths per minute 4. Patient leaning forward with arms braced on the knees

4. Patient leaning forward with arms braced on the knees

2. A 51-year-old woman has found a small lump in her breast. Which data from her history are risk factors for breast cancer? 1. Her husband's mother died from breast cancer at age 43. 2. She drinks a glass of wine each night with dinner. 3. Menarche occurred at age 14; menopause occurred at age 46. 4. She underwent radiation treatment for Hodgkin disease at age 17.

4. She underwent radiation treatment for Hodgkin disease at age 17.

6. While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss? 1. Whispered voice test 2. Rinne test 3. Weber test 4. Test using audioscope

4. Test using audioscope

9. During an eye examination, how does a nurse recognize normal accommodation? 1. The patient has peripheral vision of 90 degrees left and right. 2. The patient's eyes move up and down, side to side, and obliquely. 3. The right pupil constricts when a light is shown in the left pupil. 4. The patient's pupils dilate when looking toward a distant object.

4. The patient's pupils dilate when looking toward a distant object.

6. How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. Uses the tips of the fingers to palpate the skin over the chest and the alignment of vertebrae 4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

which vessel is the nurse assessing if the major artery of the neck is being examined? 1. temporal 2. jugular 3. radial 4. carotid

4. carotid

a 24-year-old female patient has a 2-day history of clear nasal drainage. based on these data, which question is the most logical for the nurse to ask? 1. is there a foul odor coming from your nose? 2. have you recently had nosebleeds? 3. do you snore when sleeping? 4. do you have allergies?

4. do you have allergies?

a client presents to the clinic with "sores around the mouth." the nurse notes vesicular lesions on the upper lip and right corner of the lips. the patient describes these as painful. the nurse suspects what condition? 1. syphilis 2. actinic cheilitis 3. angioedema 4. herpes simplex

4. herpes simplex

which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? 1. this indicates that the heart is working efficiently 2. the client most likely sleeps without a pillow at night 3. the client has decreased performance levels of activities of daily living 4. increased urination at rest may indicate heart failure

4. increased urination at rest may indicate heart failure

a client visit the clinic and tells the nurse that she had a mastectomy 2 years ago. the nurse should assess the client for 1. bruits over the radial artery 2. poor peripheral pulses 3, raynaud disease 4. lymphedema

4. lymphedema

a client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. the client has a condition known as what? 1. tachypnea 2. pneumonia 3. sleep apnea 4. orthopnea

4. orthopnea

the nurse is listening to the patient's heart at the 2nd LSB. which area is being auscultated? 1. Erb's point 2. mitral area 3. aortic area 4. pulmonic area

4. pulmonic area

which of the following tests should be performed to assess extraocular movements? 1. PERRLA test 2. cover-uncover eye test 3. red reflex 4. six cardinal fields of gaze

4. six cardinal fields of gaze

a student in the vascular surgery clinic is asked to perform a physical examination on a client with known peripheral vascular disease in the legs. which of the following aspects are most important to note? 1. nodules in joints 2. lower extremity strength 3. muscle bulk and tone 4. size, symmetry, and skin color

4. size, symmetry, and skin color

the nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. which members would benefit from receiving this vaccination? SATA. a. adult patient caring for children under age 5 b. young adult patient who lives alone c. adult patient with COPD d. older adult attending day care e. adolescent patient being homeschooled

a. adult patient caring for children under age 5 c. adult patient with COPD d. older adult attending day care

A patient brought to emergency department complains chest pain. This patient experience a head on collision. Patient was a restrained driver. Air bags deployed. Upon arrival, the nurse noticed that patient is having paradoxical breathing. His respiration rate is 28 breaths/minute. SaO2 is 99% on 2L oxygen through nasal cannula. Which of the following is the most appropriate assessment interpretation and nursing action? a. assessment suggests flail chest. emergency provider should be notified immediately. b. assessment suggests diabetic ketoacidosis. emergency provider should be notified immediately. c. assessment suggests pneumothorax. emergency provider should be notified immediately. d. assessment suggest funnel chest. no further intervention needed.

a. assessment suggests flail chest. emergency provider should be notified immediately.

the nursing instructor is observing a student nurse assess the client's respiratory system. which technique demonstrated by the student is most appropriate? a. from side to side b. from base to apex of lungs c. first down one side of the thorax, then down the other d. first up one side of the thorax, then up the other

a. from side to side

a female client asks a nurse when the best time to perform self-breast examination . which response by the nurse is the most appropriate? a. if you are still menstruating, the best time is about 5 days after your period begins each month b. your primary care provider can tell you when the best time is for you c. if you are postmenopausal the best time is at the beginning of the month d. it doesn't really matter as long as you keep a record of when you perform the exam

a. if you are still menstruating, the best time is about 5 days after your period begins each month

a patient asks what can be done to reduce the risk of developing breast cancer. what should the nurse instruct the patient? SATA. a. maintain a normal body weight b. wear a support bra at all times c. avoid breastfeeding d. limit exercise e. limit alcohol use

a. maintain a normal body weight e. limit alcohol use

the nurse wants to assess the apex of a client's right lung. which locations should the nurse place the stethoscope to assess this area on the client? a. near the right clavicle b. below the scapula c. near the left clavicle d. intercostal space fourth rib near the axillary line

a. near the right clavicle

the nurse auscultates the client's lungs and prepares to document the assessment. which breath sounds are considered abnormal and may require further intervention? SATA. a. wheezes b. crackles c. bronchial d. vesicular e. bronchovesicular

a. wheezes b. crackles

during a focused assessment, the female client reports tenderness, swelling, and lymph node enlargement around the time of her period. which response by the nurse is most appropriate? a. this sounds like a condition known as nodularity. it is a benign disorder so you will need to monitor your breasts monthly b. fluctuating hormone levels around the time of your period frequently cause these symptoms. I will note this in your chart and notify your PCP. c. do you have a history of fibrocystic disease? these symptoms are usually seen with this disease? d. as long as you have not detected any lumps, you have nothing to worry about.

b. fluctuating hormone levels around the time of your period frequently cause these symptoms. I will note this in your chart and notify your PCP.

the apical rate may be faster than the radial rate when the client has atrial fibrillation. T/F?

true