Physical Assessment Midterm Review

The nurse should inform the client that angina lasts less than _________ min.

15

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

"A headache is an expected adverse effect of the medication.

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

"Diuretics are the first type of medication to control hypertension."

Manifestations associated wit infective endocarditis include

Anorexia, fever and malaise, dyspnea

A nurse is caring for a client who is taking digoxin for heart failure and develops indications of severe digoxin toxicity. Which of the following medications should the nurse prepare to administer?

Fab antibody fragments

__________________ formation does not affect capillary refill.

Thrombus

Why should a client with a DVT have their affected leg eleveated?

decrease edema

The nurse should expect a ______________, rather than an_________________, in the client's platelet count because of the increased platelet consumption involved in the rapid formation of multiple clots.

decrease, increase

DIC causes bleeding in part due to a _______________________ platelet count, rather than an elevated platelet count.

decreased

Dependent rubor is a manifestation of?

peripheral arterial disease.

A nurse is assessing a client who has disseminated intravascular coagulation, which of the findings should the nurse expect?

xcessive thrombosis and bleeding

A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?

Heart rate 46/min

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegally

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?

"I eat two eggs for breakfast each morning."

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?

"I may eat 10 ounces of lean protein each day."

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my medications at the first sign of an attack."

A thrombus is more likely to cause muscle rigidity than a soft and pliable muscle.

Soft, pliable calf muscle

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

"Increasing my intake of foods containing trans-fatty acids can lower my risk.

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?

"Take one tablet at the first indication of chest pain."

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

"These tests help determine the degree of damage to the heart tissues."

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?

"Try taking a mild analgesic to relieve the headache."

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

"You might have to stop taking this medication 5 days before any planned surgeries."

A nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include?

"You should avoid grapefruit juice."

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

"You will notice a small hematoma at the incision site."

The return of color to the nail beds when testing capillary refill should occur within _________ seconds.

3

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?

A client who has renal failure, a serum potassium of 5.8/mEq/L and is prescribed sodium polystyrene sulfonate

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

A client who is postoperative following a lobectomy and has a chest tube

A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?

A client who was admitted for chest pain and is reporting a new onset of indigestion

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further?

A history of left-sided heart failure

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

Abnormally prominent U wave

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

Adjust the thermostat so that the environment is warm.

A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity?

Anorexia

A nurse is assessing a client who has infective endocarditis, which finding should be the priority for the nurse to report to the provider A. Splinter hemorrhages to the nails B. Dyspnea C. Fever D. Clusters of petechiae in the mouth

Dyspnea

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?

Dyspnea

A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply a tourniquet or BP cuff Insert the catheter. Cleanse the site with an antiseptic swab. Flush the catheter. Dilate the vein.

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following?

Arterial insufficiency

Manifestations of _____________ include cough, dyspnea and wheezing. If asthma exacerbations progress, the client might have diaphoresis, tachycardia and widening pulse pressure.

Asthma

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Auscultate for wheezing.

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for?

Dyspnea

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions?

Beans

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Blood pressure 115/68 mmHg

.A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition

Breathlessness

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Eat foods that contain plenty of potassium

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Call the emergency response team.

A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders?

Cardiovascular disease

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)

Check peripheral pulses in the affected extremity. Keep the client's hip and leg extended. Have the client remain in bed up to 6 hr.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). What statement should the nurse make

DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?

Decreased blood pressure

A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of ?

Deep vein thrombosis

is a dark red color to the feet and lower legs when the leg is in a dependent position. It is the result of dilation of the arteries as a compensatory response to poor arterial blood flow and is a manifestation that occurs in later stages of PAD.

Dependent rubor

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

Different apical and radial pulses.

A distended abdomen is a manifestation of right-sided heart failure.

Distended abdomen

a manifestation of left-sided heart failure.

Dizziness

A nurse is caring for a client who is postoperative following vascular surgery. What sign indicates to the nurse that the client has developed a thrombus?

Dull, aching calf pain

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP).

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?

Evaluating the client for nausea, vomiting, and anorexia

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Exercise at least three times per week.

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain?

Exertion and anxiety can trigger the pain.

A nurse is providing discharge instructions to a client who developed deep vein thrombosis postoperatively and is prescribed anticoagulant therapy Which of the following instructions should the nurse include?

Flexing her knees and feet frequently

a manifestation that occurs in later stages of PAD. Arterial ulcers form on or between the toes and are painful. The wound has a round, "punched out" appearance and is usually small and can develop gangrene.

Foot ulcers

A nurse assessing a client who is at risk for deep-vein thrombosis (DVT). Which of the following findings is a manifestation of DVT?

Groin tenderness

A nurse is assessing a client who has left sided heart failure, which of the following findings should the nurse expect?

Hacking cough

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

Heart failure

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

Impaired tissue perfusion

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Increased blood pressure Increased HR Increased respiratory rate

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Intermittent claudication

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Irregular

DIC is not a genetic disorder and does not involve vitamin ___________ deficiency. The effect of vitamin K is to prolong bleeding time.

K

a nurse is planning care for a client who has deep vein thrombosis of the lower leg, which of the following interventions should the nurse include in the plan of care

Keep the clients affected leg elevated while in bed

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?

LDL 172 mg/dL

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

Leg pain at rest

A nurse is assessing a male client who has advanced peripheral artery disease, What finding should the nurse expect

Leg pain at rest

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Metformin

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

Morphine

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Muffled heart sounds.

A nurse is assessing a client who has hypercholesterolemia and is receiving simvastatin. Which of the following findings should the nurse recognize as a potential adverse effect?

Muscle weakness

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)

Nausea Tachycardia Diaphoresis

A nurse is giving a presentation about preventing deep vein thrombosis DVT. Which of the following should the nurse include as a risk factor for this disorder?

Obesity, trauma, oral contraceptives and immobility

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEg/L. Which of the following actions should the nurse take?

Obtain a 12-lead ECG.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper-socks for the client

A nurse is caring for a client who reports an area of redness, warmth , tenderness and pain in the calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Obtain a venous duplex ultrasound.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

Obtain an EKG.

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria

Positive Homan's sign

Pain in the calf upon flexing the knee and arching or cramping upon dorsiflexion of the foot.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

Perform a 12-lead ECG

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Perform neurovascular checks with vital signs.

The client who has ______________ _____________ ___________ will have thickened toenails.

Peripheral artery disease

___________________ are manifestations of infective endocarditis and can appear in clusters over different areas of the body, including the mucous membranes of the mouth, the palms of the hands, and soles of the feet.

Petechiae

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Pic

A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.

Pic

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Pic

Homan's sign has shown to be unreliable since only a small percentage of clients who have a thrombus exhibit it, and performing it could possibly mobilize the clot.

Positive Homan's sign

Kernig's sign indicates meningeal irritation.

Positive Kernig's sign

A nurse is caring for a client who has a new prescription for propranolol. The nurse should monitor the client for which of the following adverse reactions to this medication?

Postural hypotension

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/84 mm Hg places him in which of the following categories?

Prehypertension

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose?

Protamine

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Protamine sulfate

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

Radial pulse in the left arm

a numbness or burning sensation to various areas of the foot, is a manifestation that occurs in later stages of PAD and can result in the loss of a limb. The discomfort, which is worse when the foot is in a horizontal or elevated position, is the result of increasing arterial insufficiency.

Rest pain

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider?

The client has a history of bronchial asthma.

A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings?

The client is experiencing premature atrial contractions.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

The client will walk for 30 min 5 days a week.

A nurse is reviewing the PT, APTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular (DIC) Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged.

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?

To reduce the risk of stroke in clients who have atrial fibrillation

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)

Troponin I Troponin T СРК Myoglobin

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis?

Vertigo

_____________ distension is a manifestation of right-sided heart failure that occurs due to venous congestion.

abdominal

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

antiplatelet aggregate

Manifestations of _____________ _____________ ______________ include dyspnea, orthopnea, nocturnal angina with diaphoresis.

aortic valve regurgitation

To test capillary refill, a nurse presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. If the skin color takes longer than 3 seconds to return to normal, this indicates impaired _____________ blood flow to the extremity.

arterial

When should the nurse apply anti embolic stockings to a patient who is going to ambulate

before ambulation

Impedance plethysmography assesses venous outflow and is useful in detecting __________ _________ the calf, but not in the lower leg.

clots above

DIC is caused by abnormal ______________ involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.

coagulation

Clients who have PAD should not wear any _______________ clothing.

constrictive

Venous duplex ultrasonography is a noninvasive diagnostic test that assesses the flow of blood and is used to detect distal_____________________

deep vein thrombosis

Thick, ___________________ are a manifestation of peripheral arterial disease.

deformed toenails

Clients who have PAD should not apply heat ____________ to a limb, because sensation is diminished and burns could result.

directly

In the initial stages of PAD, clients might experience intermittent claudication. As the disease progresses, the client will experience pain even at rest due to ischemia of the ___________ _______________. The client might describe this pain as a persistent burning or aching pain that often awakens the client at night.

distal extremities

Right-sided heart failure raises the pressure and volume within the jugular veins, making them visibly _________________when the client is sitting or the head of the bed is elevated more than 30°.

distended

A ________________ cough is a manifestation of left-sided heart failure.

dry, hacking

A nurse is assessing a client who has chronic venous insufficiency, what finding should the nurse expect?

edema

Dependent ___________ is a manifestation of right-sided heart failure. Pressing edematous skin with a finger leaves a transient indentation (pitting).

edema

Extreme _________________ of the legs can slow the flow of arterial blood to the feet.

elevation

_______________loss is a manifestation of peripheral arterial disease.

hair

Changes in sodium and fluid retention are not findings associated with DIC. The capillary leak and hemorrhage caused by DIC result in fluid loss or________________

hypovolemia

The client who has ____________ _____________and develops dyspnea, tachycardia, or a cough might be developing heart failure or experiencing pulmonary emboli, two complications of the infection.

infective endocarditis

Clients who have infective endocarditis might experience ___________________ fevers, even after initiating antibiotic therapy.

intermittent

ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain associated with claudication arises when cellular oxygen demand exceeds supply. It occurs early in the disease course, and is typically the initial reason clients who have PAD seek medical attention.

intermittent claudication

The pain of a myocardial infarction often radiates to the jaw or the back. Anginal pain often radiates to the __________arm.

left

Manifestations of __________________ include crackles or wheezes and breathlessness due to pulmonary congestion.

left sided heart failure

DIC is not controlled with lifelong heparin usage. Heparin is administered to minimize the formation of __________________, which improves tissue perfusion.

microthrombi

The nurse should apply what to the clients affected leg to promote comfort and decrease edema?

moist warm soaks

A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL DSW. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

no clue lol

The pain of myocardial infarction ___________ even with rest and organic nitrates.

persists

A______________ Homan's sign appears in only a small percentage of clients with DVT and therefore is not useful and not advised.

positive

A nurse should avoid massaging a client's leg who has a DVT because it will cause the thrombus to dislodge and result in a

pulmonary embolism

Hepatomegaly, or liver enlargement, is a manifestation of __________________ heart failure.

right sided

Fine reddish-brown lines, called ______________ ________________ are an expected finding in the client who has infective endocarditis.

slinter hemorrhages

Because of the decreased perfusion to the lower extremities, the client who has PAD will have shiny, dry skin on the legs with _____________ hair growth.

sparse

Manifestations of aortic stenosis include dyspnea, angina and ____________. As the condition progresses the client might have fatigue and peripheral cyanosis.

syncope

The client's instructions should include keeping the environment warm to prevent ________________. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction.

vasoconstriction

Capillary refill does not indicate ____________insufficiency.

venous