HA Practice ?s test 3

The nurse is percussing a male client's abdomen and notes dullness over the left lower quadrant. The client states he does not drink much water and does not have a healthy diet. What question should the nurse ask to obtain more information about the possible cause of the dullness?

"When was your last bowel movement?"

A registered nurse is teaching a nursing student about the proper techniques of an abdominal assessment. Which order of assessment stated by the nursing student indicated effective learning?

-"I will inspect the surface motion of the abdomen" -"I will note the position of the umbilicus" -"I will assess for bowel motility by auscultation -"I will palpate to assess for any abdominal tenderness"

Moderate and deep palpation of the abdomen :

-May cause tenderness -Should not detect masses -May locate the margins of the liver

The client complains of pain in her or his abdomen and nausea at mealtime. An x-ray technician also approaches at the same time for a routine x-ray. Which order of nursing actions is correct?

1- Administering the analgesic as prescribed 2- Administering medications to decrease nausea 3- Assisting the client with feeding 4- Assisting the x-ray technician for the x-ray

Neck flexion and extension should be:

45 degrees Rationale: Neck flexion and extension should each be 45 degrees. Neck flexion and extension should each be 45 degrees; rotation should be 70 degrees on each side.

How often should normal bowel sounds be heard in each quadrant of the abdomen?

5-35 times per minute

What does a goniometer measure?

Angles of extension and flexion

Auscultatory sites of the heart include:

Aortic, pulmonic, tricuspid, and mitral areas

During Auscultation of the heart, where would the nurse expect the first heart sound (s1) to the be loudest?

Apex of the Heart

A client presents with a shiny appearance of abdominal skin. The skin also has a taut appearance. Which condition does the nurse suspect the client may be presenting with?

Ascites

The nurse is performing an assessment of the carotid arteries and is wanting to assess for the presence of bruits. This is performed by using which tool?

Bell of stethoscope

A neonate begins to exhibit nasal flaring and grunting at 16 hours of age. Which is the nurse's initial action?

Elevating the head of the crib.

Which of the following is an important part of performing an abdominal assessment?

Explaining each step of the assessment to the patient.

In which position should the patient be placed in order to palpate the popliteal pulse?

Have the patient lie prone with the knee flexed.

The nurse is preparing to perform a cardiovascular assessment on a client. The nurse will perform the exam in which order?

Inspect, palpate, percuss, auscultate

What is the sequence of techniques used while assessing the abdomen?

Inspection Auscultation Percussion Palpation

The S1 heart sound:

Is louder at the apex of the heart, results from closure of the mitral and tricuspid valves, marks the start of systole

Which assessment finding would the nurse consider as abnormal?

Joint crepitation Muscle Atrophy Tenderness of the spine

What is an increases thoracic curvature, common in older adults, called?

Kyphosis

A nurse notices a cyanosis in a client with heart disease. Which site will the nurse assess to confirm cyanosis?

Lips

Which of the following findings in a musculoskeletal assessment would be considered abnormal?

Nodules and Bogginess

When auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at greater risk for heart failure?

Older adult client

A client tells the nurse, "Sometimes I have real trouble breathing. I have to sit up in order to get a good breath." The nurse assesses the client and hears fine crackles bilaterally. How will the nurse document the client's report?

Orthopnea

When palpating the carotid arteries:

Palpate one artery at a time feel for thrills

The nurse suspects a client has a distended bladder. How will the nurse assess for this condition?

Percuss and palpate the midline area above the suprapubic bone.

What should you do if a patient is ticklish when you are palpating the abdomen?

Place your hand over the patient's hand during palpation.

Normal capillary refill is less than 2 seconds and is assessed by :

Pressing on the nail bed until it blanches, and observing how quickly full color returns.

The student nurse is demonstrating auscultation of bowel sounds during a clinical check off. Where will the student place the stethoscope to begin listening to bowel sounds?

Right lower quadrant

Which of the following findings during a cardiac assessment of an adult patient are considered normal?

S1 and S2 sounds

Which musculoskeletal condition is illustrated in the figure?

Scoliosis

Which musculoskeletal abnormality would the nurse suspect in a client who exhibits short steps and drags a foot?

Spastic Gait

A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease?

Tuberculosis

After assessment, the nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which would be the cause of these sounds?

Turbulence due to muscular spasm and fluid or mucus in the larger airways.

The nurse hears an extra heart sound, S4. How will the nurse proceed with the assessment?

Turn the client to left side and listen with bell.

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?

Using several pillows at night to sleep.

The nurse is assessing a client underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?

Visceral pain

Which of the following techniques is used to assess muscle strength in a patient?

apply an opposing force or resistance

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing the carotid arteries.

bruit

Which clinical finding would the nurse expect when caring for a client who has thrombophlebitis of the left lower leg?

edema of the left calf

Where is the apical impulse located?

in the fifth intercostal space at the midclavicular line

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When would the nurse assess the symptomatic quadrant?

last

Hearing a bruit in an artery is a sign of which of the following conditions?

obstruction

What is a depression that is left after pressing a finger or thumb on swollen tissue called?

pitting edema

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties?

prone position

When should you check the patient's blood pressure to assess for orthostatic hypotension?

while the patient is sitting and standing