Health Exam 2

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

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

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

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

38. Put in correct order the steps used to palpate the liver. A. Place your right hand parallel to the right costal margin. B. Ask the patient to take a deep breath. C. Place your right hand parallel to the right costal margin. D. Lift up the eleventh and twelfth ribs with the left hand. E. Press your right hand down and under the coastal margin. F. Ask the patient to take some deep breaths

ANS: D, C, A, E, B, F

6. A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms? a. "Do you have the feeling that you cannot wait to urinate?" b. "Are you urinating a large amount each time you go to the bathroom?" c. "Has the color of your urine changed lately?" d. "Have you noticed any swelling in your ankles at the end of the day?"

ANS: A Feedback A "Do you have the feeling that you cannot wait to urinate?" is a question that asks about urgency, a symptom of incontinence. B Are you urinating a large amount each time you go to the bathroom?" is not a question related to incontinence. Usually patients with incontinence void frequently in small amounts. C Has the color of your urine changed lately?" is a question that is asked when the nurse suspects the patient has gallbladder or liver disease. D Have you noticed any swelling in your ankles at the end of the day?" is a question that relates to patients who have renal or heart disease.

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

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

17. What instructions does the nurse give a patient before palpating the abdomen? a. Bend the knees. b. Take a deep breath and hold it. c. Take a deep breath and cough. d. Place the hands over the head.

ANS: A Feedback A Bend the knees to relax the abdominal muscles. B This action is not needed to assess the abdomen. C This action is used to detect bulges in the abdomen, but not used before palpation. D This action is not needed to assess the abdomen.

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

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

1. A patient tells the nurse, "I've been having pain in my belly for several days that gets worse after eating." Which datum from the symptom analysis is consistent with the nurse's suspicion of peptic ulcer disease? a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating. b. Sharp midepigastric pain radiates to the jaw. c. Intermittent cramping pain in the left lower quadrant is relieved by defecation. d. Colicky pain is felt near the umbilicus with vomiting and constipation.

ANS: A Feedback A Gnawing epigastric pain that radiates to the back or shoulder and worsens after eating is a symptom that is consistent with peptic ulcer disease. B Sharp midepigastric pain that radiates to the jaw is not a symptom of peptic ulcer disease. C Intermittent cramping pain in the left lower quadrant relieved by defecation is a symptom of diverticular disease rather than peptic ulcer disease. D Colicky pain felt near the umbilicus with vomiting and constipation is a symptom of an intestinal obstruction rather than peptic ulcer disease.

2. A nurse determines that a patient has a heart rate of 42 beats per minute. What might be a cause of this heart rate? a. Sinoatrial (SA) node failure b. Atrial bradycardia c. A well-conditioned heart muscle d. Left ventricular hypertrophy

ANS: A Feedback A If the SA node is ineffective, the atrioventricular node may initiate contraction, but at a rate of 40 to 60 beats/min. B The heart rate reflects the ventricular rate rather than the atrial rate. C Although well-conditioned athletes may have slower heart rates, this rate is too slow for even an athlete. D Left ventricular hypertrophy alters the strength of contraction rather than the heart rate.

27. The nurse recognizes which clinical finding as expected on palpation of the abdomen? a. Inability to palpate the spleen b. Left kidney rounded at 2 cm below the costal margin c. Slight tenderness of the gallbladder on light palpation d. Bounding pulsation of the aorta over the umbilicus

ANS: A Feedback A Inability to palpate the spleen is the expected finding on palpating the abdomen. B A rounded left kidney at 2 cm below the costal margin is not an expected finding. Kidneys are usually not palpated. C Slight tenderness of the gallbladder on light palpation is not an expected finding; the gallbladder is usually not palpable. D Bounding pulsation of the aorta over the umbilicus would be an abnormal finding, perhaps indicating an aneurysm.

26. How does a nurse assess the competence of venous valves in patients who have varicose veins? a. Notes how quickly veins fill after lifting one leg above the level of the heart b. Assesses for Homan sign in both lower extremities while the patient is supine c. Assesses capillary refill on the toes of both feet while the patient is sitting in the chair d. Measures the circumference of both calves and compares the results

ANS: A Feedback A Noting how quickly veins fill after lifting one leg above the level of the heart is the procedure to test for incompetent veins. B Homan sign is an unreliable test for deep vein thrombosis. C Assessing capillary refill assesses perfusion (blood flow from arteries) rather than competence of venous valves. D Measuring the circumference of both calves and comparing the results is used to assess deep vein thrombosis.

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

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

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

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

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

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

26. On palpation of the left upper quadrant of the abdomen of a female patient, the nurse notes tenderness. This finding may indicate a disorder in which organ? a. Spleen b. Gallbladder c. Sigmoid colon d. Left ovary

ANS: A Feedback A The spleen is located in the left upper quadrant of the abdomen. B The gallbladder is located in the right upper quadrant of the abdomen. C The sigmoid colon is located in the left lower quadrant of the abdomen. D The left ovary is located in the left lower quadrant of the abdomen.

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

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

20. A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation? a. Bronchophony reveals the patient's spoken "99" as clear and loud. b. No sounds are expected since sounds cannot be transmitted through consolidation. c. Egophony reveals indistinguishable sounds when the patient says "e-e-e." d. Whispered pectoriloquy reveals a muffled sound when the patient says "1-2-3."

ANS: A Feedback A This is an abnormal finding and occurs in consolidation. B The abnormal finding is hearing a clear sound. C This is a normal finding. D This is a normal finding.

12. A nurse notices abdominal distention when inspecting a patient's abdomen. What action does the nurse take next to gain further objective data? a. Place a measuring tape around the superior iliac crests. b. Assist the patient to turn on to the left side and then the right side. c. Ask the patient to cough while lying supine. d. Use the fingertips to sharply strike one side of the abdomen.

ANS: A Feedback A This is the procedure for measuring abdominal girth. B This procedure is unnecessary. The distention will remain in a side-lying position. C Having the patient cough is used to assess for bulges rather than distention. D This is part of the procedure to test for a fluid wave, which is not indicated in this patient.

22. Which sound does a nurse expect to hear when percussing a patient's abdomen? a. Tympany over all quadrants b. Resonance over the upper quadrants and tympany in the lower quadrants c. Dull sounds over the upper quadrants and hollow sounds over the lower quadrants d. Dull sounds over the stomach and resonant sounds over the bladder

ANS: A Feedback A Tympany over all quadrants is a normal finding, which represents the presence of gas. B Resonance in the upper quadrants and tympany over the lower quadrants are not normal findings. There would be tympany in the lower quadrants, but also in the upper quadrants. C Dull sounds over the lower quadrants and hollow sounds over the upper quadrants are not normal findings. There would be tympany over the lower quadrants, but also in the upper quadrants. D Dull sounds over the stomach and resonant sounds over the bladder are not normal findings.

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

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

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

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

30. On examination, a nurse finds the patient has a productive cough with green sputum and inspiratory crackles. What other findings does this nurse expect during the examination? Select all that apply. a. Dull tones to percussion b. Increased vibration on vocal fremitus c. Fever d. Decreased diaphragmatic excursion e. A sharp, abrupt pain reported when patient breathes deeply f. Muffled sounds heard when the patient says "e-e-e"

ANS: A, B, C, E Correct: These abnormal findings are consistent with consolidation that may occur with pneumonia. Incorrect: Decreased diaphragmatic excursion occurs when the lung is overinflated as in emphysema. Muffled sounds when the patient says "e-e-e" is an expected finding. With a consolidation, the sound of "e-e-e" would be clear.

37. Alcoholism increases the risk of cancers of the gastrointestinal tract. Which cancer risk is increased in patients with alcoholism? Select all that apply. a. Esophageal cancer b. Stomach cancer c. Pancreatic cancer d. Liver cancer e. Colon cancer f. Bladder cancer

ANS: A, B, D, E Correct: The risk of esophageal, stomach, liver, and colon cancers are increased by heavy intake of alcohol. Incorrect: The risk of pancreatic and bladder cancers are increased with tobacco. However, the risk for esophageal, stomach, liver, and colon cancers are also increased with tobacco use.

28. What are the functions of the upper airways? Select all that apply. a. Conduct air to lower airway. b. Provide area for gas exchange. c. Prevent foreign matter from entering respiratory system. d. Warm, humidify, and filter air entering lungs. e. Provide transportation of oxygen and carbon dioxide between alveoli and cells.

ANS: A, C, D Correct: These are functions of the upper airway. Incorrect: Gas exchange occurs in the alveoli. The cardiovascular system provides transportation of oxygen and carbon dioxide between alveoli and cells.

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

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

4. A patient reports having abdominal distention. The nurse notices that the patient's sclerae are yellow. What question is appropriate for the nurse to ask in response to this information? a. "Has there been a change in your usual pattern of urination?" b. "Have you had any nausea or vomiting?" c. "Has there been a change in your bowel habits?" d. "Have you had indigestion or heartburn?"

ANS: B Feedback A "Has there been a change in your usual pattern of urination?" is not a question related to the abdominal distention and jaundice. B "Have you had any nausea or vomiting?" is an appropriate question because the nurse suspects the patient may have a liver disease based on the abdominal distention and jaundice. The nurse interprets the relationship with data gathered from the history and the observation. C "Has there been a change in your bowel habits?" is a question that may be related to the abdominal distention, but not the jaundice. D "Have you had indigestion or heartburn?" is not a question related to the abdominal distention and jaundice. It applies more to gastric disorders, such as gastroesophageal reflux disease or hiatal hernia.

7. In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet. Based on this finding, what question does the nurse ask the patient? a. "Have you had any pain in your abdomen?" b. "Have you had an unexpected weight gain?" c. "Have you noticed a change in the color of your skin?" d. "Have you had any nausea or vomiting?"

ANS: B Feedback A "This question does not relate to renal disease. The pain experienced with renal disease is usually flank pain over the costovertebral angle. B This question relating to weight gain and edema suggests fluid retention that occurs with renal or heart disease, particularly renal failure. C This question does not relate to renal disease. It might relate to liver or gallbladder disease if the change in skin color was yellow, indicating jaundice. D This question usually relates to disorders within the gastrointestinal tract itself and not renal disease.

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

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

3. While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination? a. An extra beat just before the S2 heart sound heard during auscultation b. A raspy machine-like or blowing sound heard during auscultation c. A prominent thrust of the heart against the chest wall felt on palpation d. A visible indentation of pericardial tissue noted during inspection

ANS: B Feedback A An extra beat just before the S1 heart sound heard during auscultation is a description of the S4 heart sound that occurs when there is hypertrophy of the ventricle. B A raspy machine-like or blowing sound heard during auscultation is a description of a murmur that can develop after rheumatic heart disease. C A prominent thrust of the heart against the chest wall felt on palpation is a description of a heave, which may occur from left ventricular hypertrophy due to increased workload. D A visible indentation of pericardial tissue noted during inspection is a description of a retraction that begins in the intercostal spaces and occurs with increased respiratory effort.

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

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

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

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

23. A patient is suspected of having a lung consolidation. A nurse uses the three techniques for assessing vocal resonance in this patient. What is the expected finding among the three procedures that will help eliminate consolidation as a problem? a. The nurse documents clearly hearing the patient say "99." b. The nurse documents hearing muffled sounds when the patient says "1-2-3." c. The nurse documents hearing no sounds when the patient says "e-e-e." d. The nurse documents clearly hearing the patient say "a-a-a."

ANS: B Feedback A Clear sounds are heard when a consolidation is present. B Muffled sounds of "1-2-3," "e-e-e," or "99" are heard when no consolidation is found. C Clear sounds are heard when a consolidation is present. D Clear sounds are heard when a consolidation is present.

8. A patient reports having abdominal distention. The nurse observes that the patient's sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patient's abdomen? a. Decreased bowel sounds in all quadrants b. Glistening or taut skin of the abdomen c. Bulge in the abdomen when coughing d. Bruit around the umbilicus

ANS: B Feedback A Decreased bowel sounds in all quadrants may be present if the abdominal distention was from an intestinal obstruction, but the observation of jaundice suggests liver disease, which does not decrease bowel sounds. B Glistening or taut skin of the abdomen is consistent with ascites that appear as abdominal distention. Jaundice and ascites suggest liver disease. There would also be an increase in abdominal girth. C A bulge in the abdomen when coughing is a finding associated with abdominal or incisional hernias. D Bruit around the umbilicus is a finding associated with an abdominal aortic aneurysm.

26. A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate on examination? a. Decreased breath sounds on auscultation b. Increased tactile fremitus and dull percussion tones c. Inspiratory wheezing found on auscultation d. Muffled sounds heard when the patient says "e-e-e"

ANS: B Feedback A Decreased breath sounds on auscultation is consistent with emphysema or atelectasis when alveoli are narrowed or destroyed. B The data describe purulent sputum and inflammation of the pleura that may occur in pneumonia. Additional findings include increased tactile fremitus and dull percussion tones, indicating congested or consolidated lung tissues. C Inspiratory wheezing found on auscultation is consistent with narrowing of bronchi that may occur in asthma. D Muffled sounds heard when the patient says "e-e-e" is a normal finding on vocal resonance (bronchophony or egophony).

35. Which assessment technique is the nurse performing in the figure below? a. Direct percussion b. Indirect percussion c. Light palpation d. Deep palpation

ANS: B Feedback A Direct percussion is performed with one hand. B Indirect percussion is the technique shown. C Light palpation is performed using the pads of the fingers depressing the tissue 1 to 2 cm, usually on the abdomen. D Deep palpation is performed using the pads of the fingers depressing the tissue 4 to 6 cm, usually on the abdomen.

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

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

30. When assessing the abdomen of a patient who has fluid in the peritoneal cavity, the nurse expects what change to occur when the patient turns from supine to the left side? a. Movement of the tympanic tones from lateral in the supine position to closer to midline when lying on the left side b. Movement of the dull tones from lateral in the supine position to closer to midline when lying on the left side c. Change in bowel sounds from hypoactive in the supine position to hyperactive when lying on the left side d. Change in bowel sounds from hyperactive in the supine position to hypoactive when lying on the left side

ANS: B Feedback A Movement of the tympanic tones from lateral in the supine position to closer to midline when lying on the left side is incorrect because the tone will be dull, rather than tympanic, due to the fluid. B Movement of the dull tones from lateral in the supine position to closer to midline when lying on the left side is the expected change when assessing for shifting dullness. C A change in bowel sounds from hypoactive in the supine position to hyperactive when lying on the left side is incorrect because bowel sounds would not be affected by the fluid. D A change in bowel sounds from hyperactive in the supine position to hypoactive when lying on the left side is incorrect because bowel sounds would not be affected by the fluid.

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

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

10. When inspecting a patient's abdomen, the nurse notes which finding as abnormal? a. Protruding abdomen with skin that is lighter in color than the arms and legs b. Marked rhythmic pulsation to the left of the midline c. Faint, fine vascular network d. Small shadows created by changes in contour

ANS: B Feedback A Obesity may cause a protruding abdomen and although obesity is not an indicator of health, it does not necessarily indicate a disease is present. B Marked rhythmic pulsation to the left of the midline is an abnormal finding that may indicate an abdominal aortic aneurysm. C A faint, fine vascular network is a normal finding. If the vessels were engorged, it would be an abnormal finding. D Small shadows created by changes in contour are a normal finding and they are seen by using a light source to inspect the contour.

13. A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next? a. Palpate lightly for tenderness and muscle tone. b. The tip of the middle finger of the dominant hand strikes the nail of the middle finger touching the skin of the abdomen. c. Palpate deeply for masses or aortic pulsation. d. Percuss for tones.

ANS: B Feedback A Palpating lightly for tenderness and muscle tone is performed after auscultation. B Auscultation for bowel sounds occurs before palpating and percussing the abdomen. C Palpating deeply for masses or aortic pulsation is performed after light palpation. D Percussion for tones is performed after palpation.

20. What technique does a nurse use when performing deep palpation of a patient's abdomen? a. Places the left hand under the ribs to lift them up b. Asks the patient to breathe slowly through the mouth c. Positions the patient on the right side with knees flexed d. Uses the heel of the hand to depress the abdomen

ANS: B Feedback A Placing the left hand under the ribs to lift them up is the technique for palpating the liver. B Asking the patient to breathe slowly through the mouth while the nurse uses the pads of the fingers to depress the abdomen is the correct procedure. C Positioning the patient on the right side with knees flexed is an alternate strategy for palpating the spleen. D Using the heel of the hand to depress the abdomen is not a correct technique; the pads of the fingers are used.

14. How does the nurse accurately assess bowel sounds? a. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant. b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant. c. Press the bell of the stethoscope firmly against the abdomen in each quadrant. d. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.

ANS: B Feedback A Pressing the diaphragm of the stethoscope firmly against the abdomen in each quadrant is not the correct technique for listening to bowel sounds. B Holding the diaphragm lightly against the abdomen in each quadrant is the correct technique for listening to bowel sounds. C The bell is used to listen to vascular sounds of the abdomen, which are normally not heard. D The bell is used to listen to vascular sounds of the abdomen, which are normally not heard.

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

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

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

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

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

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

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

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

25. Which location does a nurse select when palpating a patient's liver? a. A (right lower quadrant) b. B (right upper quadrant) c. C (left upper quadrant) d. D (left lower quadrant)

ANS: B Feedback A The majority of the liver is located in the right upper quadrant of the abdomen. B The majority of the liver is located in the right upper quadrant of the abdomen. C C is the left upper quadrant. D D is the left lower quadrant.

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

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

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

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

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

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

2. During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis? a. "Have you noticed any swelling in your ankles or feet at the end of the day?" b. "Have you noticed a change in the color of your urine or stools?" c. "Have you vomited up any blood in the last 24 hours?" d. "Have you experienced fever, chills, or sweating?"

ANS: B Feedback A This question is related to fluid retention, which may be asked if the patient has renal or heart failure. B Gallstones can obstruct the flow of bile to the gastrointestinal tract making urine darker and stools lighter in color. C This question applies if the patient has peptic ulcer disease or esophageal varices. D This question applies if the patient has gastroenteritis or a urinary tract infection.

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

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

36. A nurse suspects appendicitis in a patient with abdominal pain. Which findings are suggestive of appendicitis? Select all that apply. a. Pain radiating to the right shoulder b. Pain around the umbilicus c. Pain relieved by lying still d. Right lower quadrant pain e. Increased peristalsis

ANS: B, C, D Correct: These are all descriptions of pain related to appendicitis. Incorrect: Pain radiating to the right shoulder is associated with gallbladder disease. Increased peristalsis can be associated with gastroenteritis or diarrhea.

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

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

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

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

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

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

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

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

5. A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? a. "Has there been a change in your usual pattern of urination?" b. "Did you have heartburn before the vomiting?" c. "What did the vomitus look like?" d. "Have you noticed a change in the color of your urine or stools?"

ANS: C Feedback A "Has there been a change in your usual pattern of urination?" is not a question related to abdominal distention and vomiting. B Have you noticed a change in the color of your urine or stools?" is not a question related to abdominal distention and vomiting. It is related to elevated bilirubin from liver or gallbladder disease and is accompanied by jaundice. C "What did the vomitus look like?" is an appropriate question because the characteristics of the vomitus may help determine its cause. Acute gastritis leads to vomiting of stomach contents, obstruction of the bile duct results in greenish-yellow vomitus, and an intestinal obstruction may cause a fecal odor to the vomitus. D This is not a question related to the abdominal distention and vomiting. Heartburn applies more to gastric disorders, such as gastroesophageal reflux disease or hiatal hernia.

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

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

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

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

32. When palpating the abdomen to determine a floating mass, a nurse presses on the abdomen at a 90-degree angle with the fingertips. Which finding indicates a mass? a. An increase in abdominal girth b. A complaint from the patient of a dull pain in the flank area c. A freely movable mass will float upward and touch the fingertips d. Fluid in the abdomen will shift upward and touch the fingertips

ANS: C Feedback A An increase in abdominal girth does not occur as a result of ballottement. B A complaint from the patient of a dull pain in the flank area is not an expected finding. C A freely movable mass floating upward and touching the fingertips is the expected finding (ballottement). D Fluid in the abdomen shifting upward and touching the fingertips does not occur; it is the mass on the abdomen that shifts upward.

27. A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the significance of this finding? a. An expected finding b. Chronic obstructive pulmonary disease c. Bilateral pneumonia d. Bilateral pneumothorax

ANS: C Feedback A An increase in fremitus from normal is not an expected finding. B Air trapping in chronic obstructive pulmonary disease causes a decreased fremitus. C Increased fremitus occurs when lung tissues are congested or consolidated, which may occur in patients who have pneumonia or a tumor. D Air in the pleural space causes a decreased fremitus.

22. A nurse examines a patient with a pleural effusion and finds decreased fremitus. What additional abnormal finding should the nurse anticipate during further examination? a. An increase in the anteroposterior to lateral ratio b. Hyperresonance over the affected area c. Absent breath sounds in the affected area d. Increased vocal fremitus over the affected area

ANS: C Feedback A An increase in the anteroposterior to lateral ratio occurs in overinflated lungs as in emphysema. B Hyperresonance over the affected area occurs in overinflated lungs as in emphysema. C Absent breath sound in the affected area is anticipated because the fluid in the pleural space prevents breath sounds from being heard. D Increased vocal fremitus over the affected area is associated with consolidation that occurs with pneumonia or tumor. Fremitus is decreased to absent in pleural effusion.

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

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

11. On inspection of a female patient's abdomen, the nurse asks the patient to raise her head without using her arms and notes a midline bulge. What is the appropriate response of the nurse at this time? a. Ask the patient to cough to see if the bulge reappears. b. Auscultate the patient's abdomen for hypoactive bowel sounds. c. Document this as a normal finding and continue the examination. d. Perform light and deep palpation of the abdomen.

ANS: C Feedback A Ask the patient to cough to see if the bulge reappears. A bulge that appears with coughing is an abnormal finding revealed by the increase in intrathoracic pressure during the cough. B Auscultating the patient's abdomen for hypoactive bowel sounds is not indicated because the bulge is a normal finding. C Document this as a normal finding and continue the examination. This is a normal finding on a patient D Performing light and deep palpation of the abdomen are not indicated because the bulge is a normal finding.

29. Which techniques does a nurse use to palpate a patient's right kidney? a. Asks the patient to take a deep breath, elevates the patient's eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand b. Asks the patient to exhale, elevates the patient's eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand c. Asks the patient to take a deep breath, elevates the patient's right flank with the left hand, and deeply palpates for the right kidney with the right hand d. Asks the patient to exhale, elevates the patient's right flank with the left hand, and deeply palpates for the right kidney with the right hand

ANS: C Feedback A Asking the patient to take a deep breath, elevating the patient's eleventh and twelfth ribs with the left hand, and deeply palpating for the right kidney with the right hand is incorrect because the flank is elevated rather than the ribs. B Asking the patient to exhale, elevating the patient's eleventh and twelfth ribs with the left hand, and deeply palpating for the right kidney with the right hand is incorrect because the flank is elevated rather than the ribs and the patient is asked to inhale rather than exhale. C Asking the patient to take a deep breath, elevating the patient's right flank with the left hand, and deeply palpating for the right kidney with the right hand is the correct technique. D Asking the patient to exhale, elevating the patient's right flank with the left hand, and deeply palpating for the right kidney with the right hand is incorrect because the patient is asked to inhale rather than exhale.

24. In reviewing the patient's record, the nurse notes that the patient has air in the subcutaneous tissue. The nurse validates that this patient has crepitus with which finding? a. Asymmetric expansion of the chest wall on inhalation b. Increased transmission of vocal vibrations on auscultation c. Crackling sensation under the skin of the chest on palpation d. Coarse grating sounds heard over the mediastinum on inspiration

ANS: C Feedback A Asymmetric chest expansion occurs with rib fracture or chest wall injury. B Increased vocal fremitus occurs with lung consolidation. C A crackling sensation is the finding when crepitus is present. D Coarse grating sounds heard over the mediastinum on inspiration does not validate crepitus.

18. A patient reports intermittent cramping abdominal pain that is relieved by having a bowel movement. The patient complains of having the pain at this time, which is why she is seeking care. Which abnormal finding does the nurse anticipate finding on examination of this patient's abdomen? a. Decreased bowel sounds b. Bulge in the abdomen when coughing c. Palpable mass in the left lower quadrant d. Bruit around the umbilicus

ANS: C Feedback A Decreased bowel sounds are not expected if the patient is having bowel movements. B Bulge in the abdomen when coughing is a finding associated with abdominal or incisional hernias. C Palpable mass in the left lower quadrant is expected when interpreted with other data—age of the patient, intermittent cramping abdominal pain relieved by a bowel movement—as consistent with diverticular disease. D Bruit around the umbilicus is a finding associated with an abdominal aortic aneurysm.

24. When assessing an adult's liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurse's appropriate action at this time? a. Document this as an expected finding for this adult. b. Palpate the gallbladder for tenderness. c. Palpate the upper liver border on deep inspiration. d. Use the hooking technique to palpate the lower border of the liver.

ANS: C Feedback A Documenting this as a normal finding for an adult patient is incorrect because this finding indicates an enlarged liver. B Palpating the gallbladder for tenderness is not indicated for an enlarged liver. C Palpating the upper border of the liver on deep inspiration is the correct technique to use when an enlarged liver is found (as indicated by the liver being percussed 5 cm below the costal margin). D Using the hooking technique to palpate the lower border of the liver is not needed because the liver is enlarged.

15. When auscultating a patient's abdomen using the bell of the stethoscope, the nurse hears soft, low-pitched murmurs over the right and left upper midline. What do these sounds indicate? a. Expected peristalsis b. Femoral artery stenosis c. Renal artery stenosis d. Hyperactive bowel sounds

ANS: C Feedback A Expected peristalsis would be heard using the diaphragm of the stethoscope and would be a gurgling sound. B Femoral artery stenosis is a vascular sound heard with the bell, but located in the lower abdomen. C Renal artery stenosis is a vascular sound heard with the bell and located in the upper abdomen. D Hyperactive bowel sounds would be heard using the diaphragm and would be present in all quadrants.

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

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

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

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

33. A 75-year-old male patient asks how to reduce his risk of esophageal cancer. What is the nurse's most appropriate response? a. "Don't worry about it, esophageal cancers have a low incidence in men." b. "You should not be concerned about esophageal cancer at your age." c. "You should consider limiting your alcohol intake to two drinks per day." d. "Increasing the fiber and protein in your diet can help you lower your risk."

ANS: C Feedback A Men have a rate three times that of women. B The risk increases with age, with the peak between 70 and 80 years. C "You should consider limiting your alcohol intake to two drinks per day. Long-term alcohol intake increases your risk for esophageal cancer." D Although fiber and protein are important for the diet, their intake does not affect the risk of esophageal cancer.

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

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

28. The nurse observes a patient rocking back and forth on the examination table in pain. Based on the patient's history, the nurse suspects kidney stones. What additional examination technique does the nurse perform to confirm this suspicion? a. Palpating the flank area for rebound tenderness b. Percussing the bladder for fullness c. Percussing the costal vertebral margins for tenderness d. Palpating McBurney point for tenderness

ANS: C Feedback A Palpating the flank area for rebound tenderness is the correct location (flank area), but rebound tenderness is performed on the abdomen to detect peritoneal inflammation. B Percussing the bladder for fullness would provide data about bladder distention, but is not a technique to detect for kidney stones. C Percussing the costal vertebral margins for tenderness is the appropriate technique to detect kidney stones. The nurse recognizes the relationship between the history and the observation with further assessment techniques needed to confirm kidney stones. D Palpating McBurney point for tenderness is a technique to detect appendicitis.

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

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

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

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

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

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

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

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

21. To correctly percuss the abdomen, a nurse places the distal aspect of the middle finger of the nondominant hand against the skin of the abdomen, and the other fingers are spread apart and slightly lifted off the skin. How does the nurse use the fingers of the dominant hand? a. The pad of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen. b. The tip of the middle finger strikes the nail of the middle finger touching the skin of the abdomen. c. The tip of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen. d. The pads of the index and middle fingers strike the nail of the middle finger touching the skin of the abdomen.

ANS: C Feedback A This description is incorrect because the tip of the finger is used rather than the pad. B This description is incorrect because the distal joint is struck rather than the nail. C This is the correct technique. D This description is incorrect because the tip of the middle finger strikes the distal joint.

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

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

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

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

21. A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is the appropriate technique to use? a. Systematically percuss the posterior chest wall following the same pattern that is used for auscultation and listen for a change in tone from resonant to dull. b. Place the pads of the fingers on the right and left thoraces and palpate the texture and consistency of the skin feeling for a crackly sensation under the fingers. c. Place the palms of the hands on the right and left thoraces, ask the patient to say "99," and feel for vibrations. d. Place both thumbs on either side of the patient's spinal processes, extend fingers laterally, ask the patient to take a deep breath, and feel for vibrations.

ANS: C Feedback A This is the technique for percussing the thorax for tones. B This is the technique for detecting crepitus. C This is the correct technique for vocal fremitus. D This is not the correct technique.

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

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

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

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

23. A nurse expects which finding when assessing the abdomen of a patient who has been unable to void for 12 hours? a. Absent bowel sounds b. Hyperactive bowel sounds c. Tympanic tones over the lower abdomen d. Dull tones over the suprapubic area

ANS: D Feedback A Absent bowel sounds is incorrect because the bowel sounds would not be affected by a full bladder. B Hyperactive bowel sounds is incorrect because the bowel sounds would not be affected by a full bladder. C Tympanic tones over the lower abdomen is incorrect because tympany sound is created by gas in the abdomen. D Dull tones over the suprapubic area would be found. The urine in the bladder would create a dull sound when the bladder is percussed similar to the sounds when an abdominal mass is present.

19. Using deep palpation of a patient's epigastrium, a nurse feels a rhythmic pulsation of the aorta. Based on this finding, what is the nurse's most appropriate response? a. Auscultate this area using the bell of the stethoscope. b. Percuss the area for tones. c. Ask the patient if there is pain in this area. d. Document this as a normal finding.

ANS: D Feedback A Auscultating this area using the bell of the stethoscope is not necessary because this is a normal finding. Vascular sounds are usually not heard. B Percussing the area for tones is not necessary because this is a normal finding. C Asking the patient if there is pain in this area is not necessary because this is a normal finding. D Document this as a normal finding. The aorta is often palpable at the epigastrium.

16. What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient? a. Bowel sounds b. Venous hum c. Soft, low-pitched murmur d. No sounds

ANS: D Feedback A Bowel sounds are heard with the diaphragm of the stethoscope. B Venous hum is not a normal finding. C Soft, low-pitched murmur is not a normal finding. D The bell is used to listen for vascular sounds and normally no vascular sounds are heard in the abdomen.

12. A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes? a. Dull sounds on percussion b. Soft, muffled rhonchi heard over the trachea c. Bubbling or rasping sounds heard over the trachea d. High-pitched sounds on inspiration and exhalation

ANS: D Feedback A Dull sounds on percussion occur with pneumonia, pleural effusion, or atelectasis. B Soft, muffled rhonchi heard over the trachea is not a description of stridor. C Bubbling or rasping sounds heard over the trachea is not a description of stridor. D High-pitched sounds on inspiration and exhalation are consistent with stridor.

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

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

9. When inspecting a patient's abdomen, which finding does the nurse note as normal? a. Engorgement of veins around the umbilicus b. Sudden bulge at the umbilicus when coughing c. Visible peristalsis in all quadrants d. Silver-white striae extending from the umbilicus

ANS: D Feedback A Engorgement of veins around the umbilicus is an abnormal finding. B Sudden bulge at the umbilicus when coughing is an abnormal finding and may indicate a hernia. C Visible peristalsis in all quadrants is an abnormal finding. D Silver-white striae extending from the umbilicus is a normal finding, particularly in women who have been pregnant or in any adult who has lost weight after having an obese abdomen.

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

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

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

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

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

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

34. Which patient has the lowest risk for colon cancer? a. Patient A is 50 years old, is obese, and has type 2 diabetes mellitus. b. Patient B is 60 years old, has alcoholism, and smokes a pack of cigarettes daily. c. Patient C is 55 years old, has ulcerative colitis, and inflammatory bowel disease. d. Patient D is 45 years old and has diverticulosis.

ANS: D Feedback A Patient A has three risk factors for colon cancer. B Patient B has three risk factors for colon cancer. C Patient C has two risk factors for colon cancer. D Patient D has the lowest risk of colon cancer. Ninety percent of colon cancers occur in adults older than 50 years of age. Although this patient does have a disorder of the colon, it is not linked to an increased risk of colon cancer.

4. A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient's chest pain? a. Stable angina b. Esophageal reflux disease c. Mitral valve prolapse d. Costochondritis

ANS: D Feedback A Physical exertion, emotional stress, and cold worsen the chest pain associated with stable angina. B A spicy or acidic meal, alcohol, or lying supine may worsen the chest pain associated with esophageal reflux. C Only occasional position changes worsen the chest pain associated with mitral valve prolapse. D Coughing, deep breathing, laughing, and sneezing worsen the chest pain associated with costochondritis.

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

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

3. A patient reports having frequent heartburn. Which question does the nurse ask in response to this information? a. "Has your abdomen been distended when you feel the heartburn?" b. "What have you eaten in the last 24 hours?" c. "Is there a history of heart disease in your family?" d. "How long after eating do you have heartburn?"

ANS: D Feedback A The question "Has your abdomen been distended when you feel the heartburn?" is not related to the heartburn. Distention usually is related to intestinal obstruction or liver disease. B The question "What have you eaten in the last 24 hours?" relates more to gastroenteritis. Indigestion is usually caused by food eaten in the last meal rather than in the last 24 hours. C The question "Is there a history of heart disease in your family?" points to myocardial ischemia. Although heartburn may be a symptom of myocardial ischemia, asking the patient about the family history is not relevant in this case. D Asking "How long after eating do you have heartburn?" can aid in determining if the patient has gastroesophageal reflux disease or a hiatal hernia. Both are common disorders that cause indigestion a few hours after meals.

31. The patient reports right lower quadrant (RLQ) pain that is worse with coughing. Based on the patient's history, the nurse suspects appendicitis. What additional examination technique does the nurse perform to confirm this suspicion? a. Placing the hand over the lower right thigh and asking the patient to flex the knee while pushing down on the knee to resist it and noting if the patient complains of pain b. Palpating deeply a point of the abdomen, located halfway between the umbilicus and the left anterior iliac crest c. Asking the patient to flex the right hip and knee to 90 degrees, then abducting the leg and noting if the patient complains of pain d. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen, then releasing the fingers quickly and noting any complaint of pain

ANS: D Feedback A This is an incorrect description of the iliopsoas muscle test. B This is an incorrect description of the testing for McBurney point. McBurney point is located to the right of the umbilicus. C This is an incorrect description of the obturator muscle test. D This describes rebound tenderness, which is performed to detect peritoneal inflammation.

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

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

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

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