Health Assessment Exam 3

apex

3 to 4 cm above the inner third of the clavicles

During a cardiovascular assessment, the nurse knows that a "thrill" is: A) a vibration that is palpable. B) palpated in the right epigastric area. C) associated with ventricular hypertrophy. D) a murmur auscultated at the third intercostal space.

ANS: A A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur. Pages: 474-475

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? A) African-Americans B) Whites C) American Indians D) Hispanics

ANS: A According to the American Heart Association, the prevalence of hypertension is higher among African-Americans than in other racial groups. Page: 466

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? A) This is the result of peripheral vasodilatation and is an expected change. B) Because of increased cardiac output, the blood pressure should be higher this time. C) This is not an expected finding because it would mean a decreased cardiac output. D) This would mean a decrease in circulating blood volume, which is dangerous for the fetus.

ANS: A Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation. The blood pressure drops to its lowest point during the second trimester and then rises after that. Page: 465

The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? A) Tetralogy of Fallot B) Atrial septal defect C) Patent ductus arteriosus D) Ventricular septal defect

ANS: A Tetralogy of Fallot subjective findings include (1) severe cyanosis, not in the first months of life but developing as the infant grows, and right ventricle outflow (i.e., pulmonic) stenosis gets worse; (2) cyanosis with crying and exertion at first, then at rest; and (3) slowed development. Objective findings include (1) thrill palpable at left lower sternal border; (2) S1 normal, S2 has A2 loud and P2 diminished or absent; and (3) murmur is systolic, loud, crescendo-decrescendo. Page: 493

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as: A) normal for this age. B) lower than expected. C) higher than expected, probably as a result of crying. D) higher than expected, reflecting persistent tachycardia.

ANS: A The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants. Page: 481

The sac that surrounds and protects the heart is called the: A) pericardium B) myocardium C) Endocardium D) pleural space

ANS: A the pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. it has two layers that contain a few militaries of serous pericardial fluid Page: 457

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. A) The patient has a history of diabetes and cigarette smoking. B) The patient's skin is pale and cool. C) The patient's ankles have two small, weeping ulcers. D) The patient works long hours sitting at a computer desk. E) The patient states that the pain gets worse when walking. F) The patient states that the pain is worse at the end of the day.

ANS: A, B, E See Table 20-3. Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset, with exertion, and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems.

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. A) Intense, sharp pain, with the deep muscle tender to touch B) Aching, tired pain, with a feeling of fullness C) Pain is worse at the end of the day D) Sudden onset E) Warm, red, and swollen calf F) Pain that is relieved with elevation of leg

ANS: A, D, E Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: A) a valvular disorder. B) blood flow turbulence. C) fluid volume overload. D) ventricular hypertrophy.

ANS: B A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present. Page: 471

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n): A) split S1. B) atrial gallop. C) diastolic murmur. D) summation sound.

ANS: B A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions. It is heard best at the apex with the patient in the left lateral position. Page: 491

The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest. D) Listen for all possible sounds at a time at each specified area.

ANS: B Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time. Pages: 475-476

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: A) palpate the artery in the upper one third of the neck. B) listen with the bell of the stethoscope to assess for bruits. C) palpate both arteries simultaneously to compare amplitude. D) instruct patient to take slow deep breaths during auscultation.

ANS: B If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain. Pages: 471-472

During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be: A) marked elevational pallor. B) venous filling within 15 seconds. C) no change in coloration of the skin. D) color returning to the feet within 20 seconds of assuming a sitting position

ANS: B In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Marked elevational pallor as well as delayed venous filling occurs with arterial insufficiency.

During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? A) Venous stasis B) Lymphedema C) Arteriosclerosis D) Deep vein thrombosis

ANS: B Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and it can impede drainage of lymph. The other responses are not correct.

The nurse knows that normal splitting of the second heart sound is associated with: A) expiration. B) inspiration. C) exercise state. D) low resting heart rate

ANS: B Normal or physiologic splitting of the second heart sound is associated with inspiration because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve. Pages: 477-478

While auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings? A) S3 is indicative of heart disease in children. B) These can all be normal findings in a child. C) These are indicative of congenital problems. D) The venous hum most likely indicates an aneurysm

ANS: B Physiologic S3 is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood. Page: 482

The direction of blood flow through the heart is best described by which of these? A) Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle B) Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle C) Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava D) Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle

ANS: B Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta. Page 458

The component of the conduction system referred to as the pacemaker of the heart is the: A) atrioventricular (AV) node. B) sinoatrial (SA) node. C) bundle of His. D) bundle branches.

ANS: B Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is the "pacemaker." Pages: 461-462

During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings? A) Deep vein thrombophlebitis B) Varicose veins C) Lymphedema D) Raynaud's phenomenon

ANS: B Superficial varicose veins are caused by incompetent distant valves on veins, which results in reflux of blood and producing dilated, tortuous veins. They are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are seen on assessment. See Table 20-5 for the description of deep vein thrombophlebitis. See Table 20-2 for descriptions of Raynaud's phenomenon and lymphedema.

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: A) bell at the base with the patient leaning forward. B) bell at the apex with the patient in the left lateral position. C) diaphragm in the aortic area with the patient sitting. D) diaphragm in the pulmonic area with the patient supine.

ANS: B The S4 is a ventricular filling sound. It occurs when atria contract late in diastole. It is heard immediately before S1. This is a very soft sound with a very low pitch. The nurse needs a good bell and must listen for it. It is heard best at the apex, with the person in the left lateral position. Page: 479

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: A) lymphedema. B) Raynaud's disease. C) deep vein thrombosis. D) chronic arterial insufficiency.

ANS: B The condition with episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress is known as Raynaud's disease. Lymphedema is described in Table 20-2; deep vein thrombosis is described in Table 20-5; chronic arterial insufficiency is described in Table 20-4.

The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? A) Bounding B) Normal C) Weak D) Absent

ANS: B When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should see which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? A) The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is working properly. B) The jugular veins will remain elevated as long as pressure on the abdomen is maintained. C) An impulse will be visible at the fourth or fifth intercostal space, at or inside the midclavicular line. D) The jugular veins will not be detected during this maneuver.

ANS: B When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing; however, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained. Page: 473

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? A) Increase in resting heart rate B) Increase in systolic blood pressure C) Decrease in diastolic blood pressure D) Increase in diastolic blood pressure

ANS: B With aging, there is an increase in systolic blood pressure. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging. Pages: 465-466

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for myocardial infarction (MI)? Select all that apply. A) Ethnicity B) Abnormal lipids C) Smoking D) Gender E) Hypertension F) Diabetes G) Family history

ANS: B, C, E, F Nine modifiable risk factors for MI, as identified by a recent study, include abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol use, and regular physical activity.

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? A) "Easily palpable, pounds under the fingertips." B) "Greater than normal force, then collapses suddenly." C) "Hard to palpate, may fade in and out, easily obliterated by pressure." D) "Rhythm is regular, but force varies with alternating beats of large and small amplitude."

ANS: C A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

During a cardiovascular assessment, the nurse knows that an S4 heart sound is: A) heard at the onset of atrial diastole. B) usually a normal finding in the elderly. C) heard at the end of ventricular diastole. D) heard best over the second left intercostal space with the individual sitting upright.

ANS: C An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. The S4 occurs just before the S1. Pages: 461-462

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: A) varicosities. B) a venous stasis ulcer. C) an arterial ischemic ulcer. D) deep vein thrombophlebitis.

ANS: C Arterial ischemic ulcers occur at toes, metatarsal heads, heels, and lateral ankle, and they are characterized by a pale ischemic base, well-defined edges, and no bleeding. See Table 20-5 for a description of varicose veins and deep vein thrombophlebitis. See Table 20-4 for a description of venous stasis ulcers.

Which of these statements describes the closure of the valves in a normal cardiac cycle? A) The aortic valve closes slightly before the tricuspid valve. B) The pulmonic valve closes slightly before the aortic valve. C) The tricuspid valve closes slightly later than the mitral valve. D) Both the tricuspid and pulmonic valves close at the same time.

ANS: C Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1). Page 460

When assessing a newborn infant who is 5 minutes old, the nurse knows that which of these statements would be true? A) The left ventricle is larger and weighs more than the right ventricle. B) The circulation of a newborn is identical to that of an adult. C) There is an opening in the atrial septum where blood can flow into the left side of the heart. D) The foramen ovale closes just minutes before birth and the ductus arteriosus closes immediately after.

ANS: C First, about two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour because the pressure in the right side of the heart is now lower than in the left side. Pages: 464-465

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? A) Family history, hypertension, stress, age B) Personality type, high cholesterol, diabetes, smoking C) Smoking, hypertension, obesity, diabetes, high cholesterol D) Alcohol consumption, obesity, diabetes, stress, high cholesterol

ANS: C For major risk factors for coronary artery disease, collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 130 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level. Pages: 468-469

The nurse is performing a peripheral vascular assessment on a bedridden patient and notices the following findings in the right leg: increased warmth, swelling, redness, tenderness to palpation, and a positive Homan's sign. The nurse should: A) reevaluate the patient in a few hours. B) consider this a normal finding for a bedridden patient. C) seek emergency referral because of the risk of pulmonary embolism. D) ask the patient to raise his leg off of the bed and check for pain on elevation.

ANS: C Increased warmth, swelling, redness, and tenderness in the lower extremities require emergency referral because of the risk of pulmonary embolism from a deep vein thrombosis.

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: A) increased cardiac output. B) another myocardial infarction. C) inflammation of the precordium. D) ventricular hypertrophy resulting from muscle damage.

ANS: C Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, like sandpaper being rubbed. It is best heard with the diaphragm of the stethoscope, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, which are places where the pericardium comes in close contact with the chest wall. Page: 491

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? A) Percussion is a useful tool for outlining the heart's borders. B) Percussion is easier in obese patients. C) Studies show that percussed cardiac borders do not correlate well with the true cardiac border. D) Only expert health care providers should attempt percussion of the heart

ANS: C Numerous comparison studies have shown that the percussed cardiac border correlates "only moderately" with the true cardiac border. Percussion is of limited usefulness with the female breast tissue or in an obese person, or a person with a muscular chest wall. Chest x-rays or echocardiogram examinations are much more accurate in detecting heart enlargement. Pages: 474-475

The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His medical history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this situation? A) Enlarged, warm, tender nodes B) Lymphadenopathy of the cervical nodes C) Palpable firm, small, shotty, mobile, nontender lymph nodes D) Firm, rubbery, large nodes, somewhat fixed to the underlying tissue

ANS: C Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, tender nodes indicate current infection.

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: A) right ventricular hypertrophy. B) increased volume and size of the heart as a result of pregnancy. C) displacement of the heart from elevation of the diaphragm. D) increased blood flow through the internal mammary artery.

ANS: C Palpation of the apical impulse is higher and more lateral compared with the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis. Page: 483

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: A) "When was your last electrocardiogram?" B) "It's probably because it's been so hot at night." C) "Do you have any history of problems with your heart?" D) "Have you had a recent sinus infection or upper respiratory infection?"

ANS: C Paroxysmal nocturnal dyspnea occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air. Pages: 467-468

When listening to heart sounds, the nurse knows that S1: A) is louder than S2 at the base of the heart. B) indicates the beginning of diastole. C) coincides with the carotid artery pulse. D) is caused by closure of the semilunar valves.

ANS: C S1 coincides with the carotid artery pulse. S1 is the start of systole and is louder than S2 at the apex of the heart; S2 is louder than S1 at the base. The nurse should feel the carotid artery pulse gently while auscultating at the apex; the sound heard as each pulse is felt is S1. Pages: 476-477

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child? A) S3 when sitting up B) Persistent tachycardia above 150 C) Murmur at second left intercostal space when supine D) Palpable apical impulse in fifth left intercostal space lateral to midclavicular line

ANS: C Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction. Page: 479

he nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse? A) It is palpable in all adults. B) It occurs with the onset of diastole. C) Its location may be indicative of heart size. D) It should normally be palpable in the anterior axillary line.

ANS: C The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle. Page: 473

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique? A) While listening with the bell of the stethoscope, have the patient take a deep breath and hold it. B) While auscultating one side with the bell of the stethoscope, palpate the carotid artery on the other side to check pulsations. C) Lightly apply the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly. D) Firmly place the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly.

ANS: C The nurse should lightly apply the bell of the stethoscope over the carotid artery at three levels; while listening, the nurse should have the patient take a breath, exhale, and hold it briefly. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotids. Examine only one carotid artery at a time to avoid compromising arterial blood flow to the brain. Avoid pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope. Pages: 471-472

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? A) Talk with the patient about his intake of caffeine. B) Perform an electrocardiogram after the examination. C) No further response is needed because this is normal. D) Refer the patient to a cardiologist for further testing.

ANS: C The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration, and slowing with expiration. Pages: 476-477

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: A) mitral and tricuspid. B) tricuspid and aortic. C) aortic and pulmonic. D) mitral and pulmonic.

ANS: C The second heart sound (S2) occurs with closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base of the heart. Pages 460-461

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? A) Low humming sound B) Regular "lub, dub" pattern C) Swishing, whooshing sound D) Steady, even, flowing sound

ANS: C When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

The nurse is preparing to perform a manual compression test on a patient. Which of these statements is true about this procedure? A) Rapid filling of the veins indicates incompetent veins. B) Competent valves in the veins will transmit a wave to the distal fingers. C) A palpable wave transmission occurs when the valves are incompetent. D) The test assesses whether the valves of varicosity are competent when the person is in the supine position.

ANS: C With the manual compression test, a palpable wave transmission occurs when the valves are incompetent. Competent veins will prevent a wave transmission and the nurse's distal (lower) fingers will feel no change. The test is performed while the patient is standing.

During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what should the nurse do? A) Have the patient turn to the left side while the nurse listens with the bell. B) Ask the patient to hold his breath while the nurse listens again. C) No further assessment is needed because the nurse knows it is an S3. D) Watch the patient's respirations while listening for effect on the sound

ANS: D A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Instead, the nurse should concentrate on the split while watching the person's chest rise up and down with breathing. Pages: 477-478

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: A) decreased fluid volume. B) increased cardiac output. C) narrowing of jugular veins. D) elevated pressure related to heart failure.

ANS: D Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure. Page: 473

During an assessment, the nurse notes that the patient's apical impulse is displaced laterally, and it is palpable over a wide area. This indicates: A) systemic hypertension. B) pulmonic hypertension. C) pressure overload, as in aortic stenosis. D) volume overload, as in mitral regurgitation.

ANS: D Cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilatation are present. This is volume overload, as in mitral regurgitation, aortic regurgitation, or left-to-right shunts. Page: 492

During a cardiac assessment on a 38 year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above sternal angle when he is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty in breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? A) Fluid overload B) Atrial septal defect C) Myocardial infarction D) Heart failure

ANS: D Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue. The S3 is associated with heart failure and is always abnormal after age 35. The S3 may be the earliest sign of heart failure. Pages: 471-472

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: A) alternans. B) bisferiens. C) bigeminus. D) paradoxus.

ANS: D In pulsus paradoxus, beats have a weaker amplitude with inspiration and a stronger amplitude with expiration. It is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.

A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with: A) heart failure. B) aortic stenosis. C) pulmonary edema. D) mitral regurgitation.

ANS: D Mitral regurgitation subjective findings include fatigue, palpitation, and orthopnea. Objective findings are (1) a thrill in systole at apex, (2) lift at apex, (3) apical impulse displaced down and to the left, (4) S1 diminished, S2 accentuated, S3 at apex often present, and (5) murmur: pansystolic, often loud, blowing, best heard at apex, radiating well to the left axilla. Page: 495

During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests: A) a normal heart. B) a systolic murmur. C) enlargement of the left ventricle. D) enlargement of the right ventricle.

ANS: D Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex. Pages: 473-474

The electrical stimulus of the cardiac cycle follows which sequence? A) AV node SA node bundle of His B) Bundle of His AV node SA node C) SA node AV node bundle of His bundle branches D) AV node SA node bundle of His bundle branches

ANS: D Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so that the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles. Pages: 461-462

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular line

ANS: D The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line. Pages: 473-474

Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon

ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen.

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? A) The infant's sleeping position B) Sibling history of eating disorders C) Amount of background noise when eating D) Presence of dyspnea or diaphoresis when sucking

ANS: D To screen for heart disease in an infant, focus on feeding. Note fatigue during feeding. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic and then falls into exhausted sleep and awakens after a short time hungry again. Pages: 469-470

The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick? A) The atria contract during systole and attempt to push against closed valves. B) The contraction of the atria at the beginning of diastole can be felt as a palpitation. C) This is the pressure exerted against the atria as the ventricles contract during systole. D) The atria contract toward the end of diastole and push the remaining blood into the ventricles.

ANS: D Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the "atrial kick." Pages 458-459

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? A) Normal ABI indices are from 0.50 to 1.0. B) The normal ankle pressure is slightly lower than the brachial pressure. C) The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals. D) An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication.

ANS: D Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a falsely high ankle pressure.

posterior apex

C7

Briefly relate the route of a blood cell from the liver to tissue in the body.

Liver to right atrium via inferior vena cava, through tricuspid valve to right ventricle, through pulmonic valve to the pulmonary artery, picks up oxygen in the lungs, returns to left atrium, to left ventricle via mitral valve, through aortic valve to aorta, and out to the body.

List the major risk factors for heart disease and stroke in the text.

The major risk factors for heart disease and stroke are hypertension, smoking, high cholesterol levels, obesity, and diabetes. Physical inactivity, family history of heart disease, and age are other risk factors.

Endocardium

Thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

A barrel-shaped chest is characterized by: a) equal anteroposterior-to-transverse diameter and ribs being horizontal. b) anteroposterior-to-transverse diameter of 1:2 and an elliptical shape. c) anteroposterior-to-transverse diameter of 2:1 and ribs being elevated. d) anteroposterior-to-transverse diameter of 3:7 and ribs sloping back.

a

A function of the venous system is: a) to hold more blood when blood volume increases b) to conserve fluid and plasma proteins that leak out of the capillaries c) to form a major part of the immune system that defends the body against disease d) to absorb lipids from the intestinal tract.

a

A known risk factor for venous ulcer development is: a) obesity b) male gender c) history of hypertension d) daily aspirin therapy

a

Atrophic skin changes that occur with peripheral arterial insufficiency include: a) thin, shiny skin with loss of hair b) brown discoloration c) thick, leathery skin d) slow-healing blisters on the skin

a

Select the statement that best differentiates a split S2 from S3. a) S3 is lower pitched and is heard at the apex. b) S2 is heard at the left lower sternal border. c) The timing of S2 varies with respirations. d) S3 is heard at the base; timing varies with respirations.

a

Symmetric chest expansion is best confirmed by: a) placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch up a small fold of skin between the thumbs. b) inspection of the shape and configuration of the chest wall. c) placing the palmar surface of the fingers of one hand against the chest and having the person repeat the words "ninety-nine". d) percussion of the posterior chest

a

The examiner wishes to listen for a pericardial friction rub. Select the best method of listening. a) with the diaphragm, patient sitting up and leaning forward, breath held in expiration b) using the bell with the patient leaning forward c) at the base during normal respiration d) with the diaphragm, patient turned to the left side

a

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

a

The pulse oximeter measures: a) arterial oxygen saturation b) venous oxygen saturation c) combined saturation of arterial and venous blood. d) carboxyhemoglobin levels.

a

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

a

barrel chest

anteroposterior = transverse diameter

Fill in the following blanks: S1 is best heard at the ____ of the heart, whereas S2 is loudest at the ____ of the heart. S1 coincides with the pulse in the ______________ and coincides with the ___ wave if the patient is on an ECG monitor.

apex; base; carotid artery; R.

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

b

Arteriosclerosis is the: a) deposition of fatty plaques on the intima of the arteries. b) loss of elasticity of the walls of blood vessels. c) loss of lymphatic tissue that occurs in the aging process. d) progressive enlargement of the intramuscular valf veins.

b

Atrial systole occurs: a) during ventricular systole. b) during ventricular diastole c) concurrently with ventricular systole d) independently of ventricular function.

b

Auscultation of breath sounds is an important component of respiratory assessment. Select the most accurate description of this part of the examination. a) Hold he bell of the stethoscope against the chest wall; listen to the entire right field and then the entire left field. b) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons. c) Listen from the apices to the bases of each lung field using the bell of the stethoscope. d) Select the bell or diaphragm depending upon the quality of sounds heard; listen for one respiration in each location, moving from side to side.

b

In order to use the technique of egophany, ask the patient to: a) take several deep breaths and then hold for 5 seconds b) say "eeeee" each time the stethoscope is moved. c) repeat the phrase "ninety-nine" each time the stethoscope is moved. d) whisper a phrase as auscultation is performed.

b

Murphy sign is best described as: a) the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix b) pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gall bladder. c) a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle. d) not a valid examination technique

b

Select the best description of bronchiovesicular breath sounds: a) high pitched, of longer duration on inspiration than expiration b) moderate pitched, inspiration equal to expiration c) low pitched, inspiration greater than expiration d) rustling sound, like the wind in the trees.

b

Select the best description of the tricuspid valve. a) left semilunar valve b) right atrioventricular valve. c) left atrioventricular valve. d) right semilunar valve.

b

Select the correct description of the left lung. a) narrower than the right lung with three lobes b) narrower than the right lung with two lobes c) wider than the right lung with two lobes d) shorter than the right lung with three lobes

b

Some conditions have a cough with characteristic timing. The cough associated with chronic bronchitis is best described as: a) continuous throughout the day b) productive cough for at least 3 months of the year for 2 years in a row c) occurring in the afternoon/evening because of exposure to irritants at work d) occurring in the early morning

b

The examiner is palpating the apical impulse. The normal size of this impulse: a) is less than 1cm b) is about 2 cm c) is 3 cm d) varies depending on the size of the person

b

The examiner wishes to listen in the pulmonic valve area. To do this, the stethoscope would be placed at the: a) second right interspace b) second left interspace c) left lower sternal border d) fifth interspace, left midclavicular line

b

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

b

You will hear a split S2 most clearly in what area? a) apical b) pulmonic c) tricuspid d) aortic

b

A murmur heard after S1 and before S2 is classified as: a) diastolic (possibly benign). b) diastolic (always pathologic). c) systolic (possibly benign). d) systolic (always pathologic).

c

A pleural friction rub is best detected by: a) observation b) palpation c) auscultation d) percussion

c

Absence of the diaphragmatic excursion occurs with: a) asthma b) an unusually thick chest wall c) pleural effusion of atelectasis of the lower lobes d) age-related changes in the chest wall

c

The function of the pulmonic valve is to: a) divide the left atrium and left ventricle. b) guard the opening between the right atrium and right ventricle. c) protect the orifice between the right ventricle and the pulmonary artery. d) guard the entrance to the aorta from the left ventricle.

c

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

c

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

c

Upon examining a patient's nails, you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with: a) adult respiratory distress syndrome b) normal findings for the nails c) chronic congenital heart disease and COPD. d) atelectasis.

c

When examining for tactile fremitus, it is important to: a) have the patient breathe quickly b) ask the patient to cough c) palpate the chest symmetrically d) use the bell of the stethoscope

c

After examining a patient, you make the following notation: Increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with a diagnosis of: a) bronchitis b) asthma c) pleural effusion d) lobar pneumonia

d

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

d

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

d

Upon examination of a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient complains of pain with breathing. These findings are consistent with: a) fine crackles b) wheezes c) atelectatic crackles d) pleural friction rub

d

normal chest

elliptical shape with an anteroposterior:transverse diameter in the ratio of 1:2

Pericardial fluid

ensures smooth, friction-free movement of the heart muscle

Kyphosis

exaggerated posterior curvature of thoracic spine

lateral right

fifth intercostal

pectus carinatum

forward protrusion of the sternum with ribs sloping back at either side

scoliosis

lateral S-shaped curvature of the thoracic and lumbar spine

Ventricle

muscular pumping chamber

Myocardium

muscular wall of the heart

Atrium

reservoir for holding blood

base

rests on the diaphragm

lateral left

sixth rib, midclavicular line

Pectus excavatum

sunken sternum and adjacent cartilages

Pericardium

tough, fibrous, double-walled sac that surrounds and protects the heart

The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? A) African-Americans B) Hispanics C) Whites D) Asians

ANS: A A recent study found lactose-intolerance prevalence estimates as follows: 19.5% for African-Americans, 10% for Hispanics, and 7.72% for whites.

A nurse notices that a patient has ascites, which indicates the presence of: A) fluid. B) feces. C) flatus. D) fibroid tumors.

ANS: A Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: A) pain related to lymphatic abnormalities. B) problems related to arterial insufficiency. C) problems related to venous insufficiency. D) pain related to musculoskeletal abnormalities.

ANS: B Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? A) A bruit is absent. B) Femoral pulses are increased. C) A pulsating mass is usually present. D) Most are located below the umbilicus.

ANS: C Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.

ANS: C Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.

A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: A) obese. B) herniated. C) scaphoid. D) protuberant.

ANS: D A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7. A scaphoid abdomen caves inward.

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.

ANS: D Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.

ANS: D Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? A) The spleen can be enlarged as a result of trauma. B) The spleen is normally felt upon routine palpation. C) If an enlarged spleen is noticed, then the nurse should palpate thoroughly to determine size. D) An enlarged spleen should not be palpated because it can rupture easily.

ANS: D If an enlarged spleen is felt, then the nurse should refer the person but should not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation.

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: A) splenomegaly. B) distended bladder. C) constipation. D) ascites.

ANS: D If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should: A) document the presence of hepatomegaly. B) ask additional history questions regarding his alcohol intake. C) describe this as an enlarged liver and refer him to a physician. D) consider this a normal finding and proceed with the examination.

ANS: D The average liver span in the midclavicular line is 6 to 12 cm. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 10 cm is within normal limits for this individual.

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: A) nonpitting, hard edema occurs with lymphatic obstruction. B) alterations in arterial function will cause this edema. C) phlebitis of a superficial vein will cause bilateral edema. D) long-standing arterial obstruction will cause pitting edema.

ANS: A Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema).

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: A) 1 minute. B) 5 minutes. C) 10 minutes. D) 2 minutes in each quadrant.

ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.

A patient has a positive Homans' sign. The nurse knows that a positive Homans' sign may indicate: A) venous insufficiency. B) deep vein thrombosis. C) severe edema. D) problems with arterial circulation.

ANS: B Calf pain on dorsiflexion of the foot is a positive Homans' sign, which occurs in about 35% of deep vein thromboses. It also occurs with superficial phlebitis, Achilles tendinitis, and gastrocnemius and plantar muscle injury.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.

ANS: B Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.

When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? A) Document the finding. B) Auscultate the site for a bruit. C) Check for calf pain. D) Check capillary refill in the toes.

ANS: B If a pulse is weak or diminished at the femoral site, the nurse should auscultate for a bruit. Presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct.

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? A) Excessive swelling of the lymph nodes B) The presence of palpable lymph nodes C) No nodes palpable because of the immature immune system of a child D) Fewer numbers and a smaller size of lymph nodes compared with those of an adult

ANS: B Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

Auscultation of the abdomen may reveal bruits of the ________________ arteries. a) aortic, renal, iliac, and femoral b) jugular, aortic, carotid, and femoral c) pulmonic, aortic, and portal d) renal, iliac, internal jugular, and basilic

a

Shifting dullness is a test for: a) ascities b) splenic enlargement c) inflammation of the kidney d) hepatomegaly

a

Raynaud's phenomenon occurs: a) when the patient's extremities are exposed to heat and compression. b) in hands and feet as a result of exposure to cold, vibration, and stress. c) after removal of lymph nodes or damage to lymph nodes and channels. d) as a result of leg cramps due to excessive walking of climbing stairs.

b

The examiner wishes to assess for arterial deficit in the lower extremities. After raising the legs 12 inches off the table and then having the person sit up and dangle the leg, the color should return in: a) 5 seconds or less b) 10 seconds or less c) 15 seconds. d) 30 seconds.

b

Inspection of a person's right hand reveals a red, swollen area. To further assess for infection, you would palpate the: a) cervical node b) axillary node c) epitrochlear node d) inguinal node

c

Intermittent claudication is: a) muscular pain relieved by exercise b) neurologic pain relieved by exercise. c) muscular pain brought on by exercise d) neurologic pain brought on by exercise

c

Select the sequence of techniques used during an examination of the abdomen: a) percussion, inspection, palpation, auscultation b) inspection, palpation, percussion, auscultation c) inspection, auscultation, percussion, palpation d) auscultation, inspection, palpation, percussion

c

Tenderness during abdominal palpation is expected when palpating: a) the liver edge b) the spleen c) the sigmoid colon d) the kidneys

c

The absence of bowel sounds is established after listening for: a) 1 full minute b) 3 full minutes c) 5 full minutes d) none of the above

c

A 54-year-old woman with five children has varicose veins of the lower extremities. Her most characteristic sign is: a) reduced arterial circulation b) blanching, deathlike appearance of the extremities on elevation c) loss of hair on feet and toes d) dilated, tortuous superficial bluish vessels.

d

A positive Blumberg sign indicates: a) a possible aortic aneurysm. b) the presence of renal artery stenosis. c) an enlarged, nodular liver. d) peritoneal inflammation.

d

Hyperactive bowel sounds are: a) high pitched b) rushing c) tinkling d) all of the above

d

Striae, which occur when the elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching, have a distinct color when of long duration. This color is: a) pink b) blue c) purple-blue d) silvery white

d

The range of normal liver span in the right midclavicular line in the adult is: a) 2-6cm b) 4-8cm c) 8-14cm d) 6-12cm

d

The upper left quadrant (LUQ) contains the: a) liver b) appendix c) left ovary d) spleen

d

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

d

A dull percusison note forward of the left midaxillary line is: a) normal, an expected finding during splenic percussion b) expected between the 8th and 12th ribs. c) found if the examination follows a large meal d) indicative of splenic enlargement

d

The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: A) diarrhea. B) pyrosis. C) dysphagia. D) constipation.

ANS: B Pyrosis, or heartburn (not constipation), is caused by esophageal reflux during pregnancy. The other options are not correct.

To screen for deep vein thrombosis, you would: a) measure the circumference of the angle. b) check the temperature with the palm of the hand. c) compress the dorsalis pedis pulse, looking for blood return. d) measure the widest point with a tape measure.

d

Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? A) "It should fall off by 10 to 14 days." B) "It will soften before it falls off." C) "It contains two veins and one artery." D) "Skin will cover the area within 1 week."

ANS: A At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton jelly. The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days. Skin will cover the area by 3 to 4 weeks.

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? A) Intraluminal valves ensure unidirectional flow toward the heart. B) Contracting skeletal muscles milk blood distally toward the veins. C) The high-pressure system of the heart helps to facilitate venous return. D) Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

ANS: A Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

How should the nurse document mild, slight pitting edema present at the ankles of a pregnant patient? A) 1+/0-4+ B) 3+/0-4+ C) 4+/0-4+ D) Brawny edema

ANS: A If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: A) claudication. B) sore muscles. C) muscle cramps. D) venous insufficiency.

ANS: A Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes. The other responses are not correct.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: A) projectile vomiting. B) hypoactive bowel activity. C) palpable olive-sized mass in right lower quadrant. D) pronounced peristaltic waves crossing from right to left.

ANS: A Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance

ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note.

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? A) Dullness across the abdomen B) Flatness in the right upper quadrant C) Hyperresonance in the left upper quadrant D) Tympany in the right and left lower quadrants

ANS: A The presence of fluid causes a dull sound to percussion. A large amount of ascitic fluid would produce a dull sound to percussion.

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? A) Spleen B) Sigmoid colon C) Appendix D) Gallbladder

ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.

During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to: A) an enlarged liver. B) an enlarged spleen. C) distended bowel. D) excessive diarrhea.

ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? A) Woman in her second month of pregnancy B) Person who has been on bed rest for 4 days C) Person with a 30-year, 1 pack per day smoking history D) Elderly person taking anticoagulant medication

ANS: B At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? A) "We need to determine areas of tenderness before using percussion and palpation." B) "It prevents distortion of bowel sounds that might occur after percussion and palpation." C) "It allows the patient more time to relax and therefore be more comfortable with the physical examination." D) "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."

ANS: B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? A) They are usually loud, high-pitched, rushing, tinkling sounds. B) They are usually high-pitched, gurgling, irregular sounds. C) They sound like two pieces of leather being rubbed together. D) They originate from the movement of air and fluid through the large intestine.

ANS: B Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: A) increased gastric acid secretion. B) decreased gastric acid secretion. C) delayed gastrointestinal emptying time. D) increased gastrointestinal emptying time.

ANS: B Gastric acid secretion decreases with aging, and this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium

The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true? A) The abdominal tone is increased. B) The abdominal musculature is thinner. C) Abdominal rigidity with acute abdominal conditions is more common. D) The aging person complains of more pain with an acute abdominal condition than a younger person would.

ANS: B In the aging person, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with acute abdominal conditions is less common in aging. The aging person often complains less of pain than a younger person would with an acute abdominal condition.

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? A) Obturator test B) Test for Murphy's sign C) Assess for rebound tenderness D) Iliopsoas muscle test

ANS: B Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? A) "Lymph flow is propelled by the contraction of the heart." B) "The flow of lymph is slow compared with that of the blood." C) "One of the functions of the lymph is to absorb lipids from the biliary tract." D) "Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream."

ANS: B The flow of lymph is slow compared with that of the blood. Lymph flow is not propelled by the heart, but rather by contracting skeletal muscles, pressure changes secondary to breathing, and by contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves, so flow is one way from the tissue spaces to the bloodstream.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? A) Hard and fixed cervical nodes B) Enlarged and tender inguinal nodes C) Bilateral enlargement of the popliteal nodes D) "Pellet-like" nodes in the supraclavicular region

ANS: B The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? A) "No need to worry. Most men your age develop hernias." B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." C) "This hernia is a result of prenatal growth abnormalities that are just now causing problems." D) "I'll have to have your physician explain this to you."

ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: A) examine the tender area first. B) examine the tender area last. C) avoid palpating the tender area. D) palpate the tender area first and then auscultate for bowel sounds.

ANS: B The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is done before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.

ANS: B The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

Which of these statements is true regarding the arterial system? A) Arteries are large-diameter vessels. B) The arterial system is a high-pressure system. C) The walls of arteries are thinner than those of veins. D) Arteries can expand greatly to accommodate a large blood volume increase

ANS: B The pumping heart makes the arterial system a high-pressure system.

The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? A) Have the patient assume a prone position. B) Ask the patient to bend his or her knees to the side in a froglike position. C) Press firmly against the bone with the patient in a semi-Fowler position. D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.

ANS: B To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.

During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line

ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).

The nurse knows that during an abdominal assessment, deep palpation is used to determine: A) bowel motility. B) enlarged organs. C) superficial tenderness. D) overall impression of skin surface and superficial musculature.

ANS: B With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A) Test for Murphy's sign. B) Test for Blumberg's sign. C) Test for shifting dullness. D) Perform iliopsoas muscle test. E) Test for fluid wave.

ANS: B, D Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse. A) normal B) absent C) bounding D) weak, thready

ANS: C A full, bounding pulse occurs with hyperkinetic states (such as exercise, anxiety, fever), anemia, and hyperthyroidism. Absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease.

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A) To measure the rate of lymphatic drainage B) To evaluate the adequacy of capillary patency before venous blood draws C) To evaluate the adequacy of collateral circulation before cannulating the radial artery D) To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

ANS: C A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test.

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: A) gallbladder disease. B) overuse of laxatives. C) gastrointestinal bleeding. D) localized bleeding around the anus.

ANS: C Black stools may be tarry as a result of occult blood (melena) from ga

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: A) aphasia. B) dysphasia. C) dysphagia. D) anorexia.

ANS: C Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg. A) venous obstruction of B) claudication due to venous abnormalities in C) ischemia caused by partial blockage of an artery supplying D) ischemia caused by complete blockage of an artery supplying

ANS: C Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: A) check for the presence of claudication. B) refer the individual for further evaluation. C) consider this a normal finding and proceed with the peripheral vascular evaluation. D) ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

ANS: C It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.

The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? A) Ask the patient about a past history of frostbite. B) Suspect that the patient has a venous insufficiency problem. C) Consider this a delayed capillary refill time and investigate further. D) Consider this a normal capillary refill time that requires no further assessment.

ANS: C Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms? A) Appendicitis B) Gastric ulcer C) Duodenal ulcer D) Cholecystitis

ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal, yet it is relieved by more food. Chronic pain associated with gastric ulcers occurs usually on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: A) flatness, resonance, and dullness. B) resonance, dullness, and tympany. C) tympany, hyperresonance, and dullness. D) resonance, hyperresonance, and flatness.

ANS: C Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

ANS: C Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: A) ovary infection. B) liver enlargement. C) kidney inflammation. D) spleen enlargement.

ANS: C Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct.

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? A) Spleen B) Sigmoid C) Appendix D) Gallbladder

ANS: C The appendix is located in the right lower quadrant, and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant.

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. A) ulnar B) radial C) brachial D) deep palmar

ANS: C The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor

ANS: C The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? A) A unilateral cool foot B) Thin, shiny, atrophic skin C) Pallor of the toes and cyanosis of the nail beds D) A brownish discoloration to the skin of the lower leg

ANS: D A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that: A) bruits are often associated with venous disease. B) bruits occur in the presence of lymphadenopathy. C) hypermetabolic states will cause bruits in the femoral arteries. D) bruits occur with turbulent blood flow, indicating partial occlusion.

ANS: D A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: A) "Venous insufficiency is a common problem after this type of surgery." B) "Oh, we have lots of veins—you won't even notice that it has been removed." C) "You will probably experience decreased circulation after the veins are removed." D) "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."

ANS: D As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation. The other responses are not correct.

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. A) flat B) convex C) bulging D) concave

ANS: D Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane. See Figure 21-7.

To detect diastasis recti, the nurse should have the patient perform which of these maneuvers? A) Relax in the supine position. B) Raise the arms in the left lateral position. C) Raise the arms over the head while supine. D) Raise the head while remaining supine.

ANS: D Diastasis recti is a separation of the abdominal rectus muscles, which can occur congenitally, as a result of pregnancy, or from marked obesity. This is assessed by having the patient raise the head while remaining supine.

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: A) increased salivation. B) increased liver size. C) increased esophageal emptying. D) decreased gastric acid secretion.

ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases

The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem? A) Hypertension B) Streptococcus infections C) History of constipation and frequent laxative use D) Frequent use of nonsteroidal antiinflammatory drugs

ANS: D Peptic ulcer disease occurs with frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? A) Behind the knee B) Over the lateral malleolus C) In the groove behind the medial malleolus D) Lateral to the extensor tendon of the great toe

ANS: D The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. There is no pulse palpated at the lateral malleolus.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? A) Assess the patient's abdomen, and notice any tenderness. B) Carefully assess the cervical lymph nodes, and check for any enlargement. C) Ask additional history questions regarding any recent ear infections or sore throats. D) Examine the patient's lower arm and hand, and check for the presence of infection or lesions.

ANS: D The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

Which of these veins are responsible for most of the venous return in the arm? A) Deep B) Ulnar C) Subclavian D) Superficial

ANS: D The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

What is the significance of black stools? Contrast this with the significance of red blood in stools.

Black, tarry stools indicate the present of occult blood (melena) from bleeding higher in the gastrointestinal tract. The blood has been partially broken down during the digestive process. Black, nontarry stools may be caused by ingesting iron supplements. Red blood in stools occurs with localized bleeding in the lower gastrointestinal tract and around the anus, such as occurs with hemorrhoids.

Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because: a) bowel sounds are always normally present here b) peristalsis through the descending colon is usually active c) this is the location of the pyloric sphincter d) vascular sounds are best heard in this area

a

During the examination of the lower extremities, you are unable to palpate the popliteal pulse. You should: a) proceed with the examination. It is often impossible to palpate this pulse. b) refer the patient to a vascular surgeon for further evaluation. c) schedule the patient for a venogram. d) schedule the patient for an ateriogram.

a

Right upper quadrant tenderness may indicate pathology in the: a) liver, pancreas, or ascending colon b) liver and stomach c) sigmoid colon, spleen, or rectum d) appendix or ileocecal valve

a

Brawny edema is: a) acute in onset. b) soft. c) nonpitting. d) associated with diminished pulses.

c

Ms. T. has come for a prenatal visit. She complains of dependent edema, varicosities in the legs, and hemorrhoids. The best response is: a) "If these symptoms persist, we will perform an amniocentesis." b) "If these symptoms persist, we will discuss having you hospitalized." c) "The symptoms are caused by the pressure of the growing uterus on the veins. They are usual conditions of pregnancy." d) "At this time, the symptoms are a minor inconvenience. You should learn to accept them."

c

The organs that aid the lymphatic system are: a) liver, lymph nodes, and stomach b) pancreas, small intestine, and thymus c) spleen, tonsils, and thymus d) pancreas, spleen, and tonsils

c

Which of the following may be noted through inspection of the abdomen? a) fluid waves and abdominal contour b) umbilical eversion and Murphy sign c) venous pattern, peristaltic waves, and abdominal contour d) peritoneal irritation, general tympany, and peristaltic waves

c