Health Assessment Exam 2
What are the primary muscles of respiration? A. External obliques and pectoralis major B. Trapezii and rectus abdominis C. Sternomastoids and scaleni D. Diaphragm and intercostals
D. Diaphragm and intercostals
The nurse is educating a 55-year-old client on breast self-examination (BSE.) Which of these statements by the client indicates understanding of the information provided? "The best time for postmenopausal women to perform BSEs is____________" a. "On the same day every month." b. "Daily, when I shower or bathe." c. "One week after my menstrual period." d. "Annually with my annual gynecologic examination."
a. "On the same day every month."
During an assessment, the nurse notices that the client's umbilicus is enlarged and everted. The nurse recognizes this as: a. Abnormal: May be an umbilical hernia b. A normal result of aging c. Likely caused by constipation d. A rare occurrence
a. Abnormal: May be an umbilical hernia
A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess? A.Thyroid B.Parathyroid C.Parotid D.Adrenal
A.Thyroid
The nurse is listening to the breath sounds of a client with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A.Wheezes B.Bronchial sounds C.Bronchophony D.Crackles
A.Wheezes
Which of the following is an appropriate position to have the client assume when auscultating for extra heart sounds or murmurs? A: Roll toward the left side B: Roll toward the right side C: Trendelenburg position D: Prone position
A: Roll toward the left side
When assessing a client's lungs, what should the nurse recall about the left lung? A. Is shorter than the right lung because of the underlying stomach B. Consists of two lobes C. Primarily consists of an upper lobe on the posterior chest D. Is divided by the horizontal fissure
B. Consists of two lobes
A clinical manifestation common in a client with chronic obstructive pulmonary disease (COPD) is: A.Periodic breathing patterns B.Pursed lip breathing C.Unequal chest expansion D.Hyperventilation
B.Pursed lip breathing
When you listen to Joe's chest anteriorly the sound you hear that would be concerning is A. Bronchial B. Bronchovesicular C. Vesicular D. Fine rales (crackles) E. Stridor
D. Fine rales (crackles)
How should the nurse document mild, slight pitting edema on the ankles of a heart failure client? •A. 1+ •B. 2+ •C. 3+ •D. 4+
A. 1+
A significant increase in the size of the thyroid gland due to hyperthyroidism or hypothyroidism is called: A)thyroiditis. B)goiter. C)thyroid nodule. D)parotiditis.
B) goiter.
The nurse is assessing a client's lungs by using the percussion technique. Which sound would the nurse expect to hear over healthy lung tissue? A. Resonance B. Dullness C. Crackles D. Wheezes
A. Resonance
As you listen to Joe's anterior chest you hear the following sound over his large airway this sound is: A. Rales B. Rhonchi C. Bronchial D. Bronchovesicular
C. Bronchial
When performing the Hirschberg test (corneal light reflex), the results will indicate whether: A) the eyes are in parallel alignment. B) the pupils are equal and reactive. C) the sympathetic and parasympathetic divisions are in balance. D) the lenses of each eye are clear.
A) the eyes are in parallel alignment.
Normal lymph nodes that are unsuspicious are described as: A)non-tender, soft, discrete, and movable. B)non-tender, discrete, and fixed. C)tender, movable, and hard. D)non-tender, non-movable, and firm.
A)non-tender, soft, discrete, and movable.
Joe has a productive cough. As the nurse, you would assess the sputum for (select all that apply) A. Color B. Consistency C. Amount D. Odor E. Clear or cloudy
A, B, C, D, & E
The nurse is educating the client about risk factors for cardiovascular disease. Which of the following risk factors for cardiovascular disease are modifiable? Select all that apply. A: Abnormal lipids B: Smoking C: Gender D: Hypertension E: Diabetes F: Family history
A, B, D, E
The nurse is performing an assessment on a client. Which of the following should the nurse ask to obtain subjective data related to the client's gastrointestinal system? Select all that apply a.Have you experienced any changes in bowel habits? b.What medications are you taking? c. Do you have any headaches? d. Do you have any dysphagia? e. Are you experiencing any nausea or vomitting?
A, B, D, E
The nurse is asking the client for subjective data before performing a cardiac and great vessel assessment. Which of the following should the nurse ask? Select all that apply •A) Do you ever have any dyspnea? •B) Have you noticed any edema? •C) Do you have any history of respiratory infections? •D)Have you noticed any skin pigmentation changes? •E) Have you had any chest pain?
A, B, E
What should you look for to assess Joe's respiratory effort (select all that apply) A. Respiratory rate B. Respiratory pattern C. Depth of each respiration D. Use of chest, shoulder, neck and abdominal muscles when breathing E. Breathing through the mouth
A,B,C,D,E
Which of the following subjective data would the nurse want to collect for the client when performing a Head, Face and Neck Exam? (Select all that apply) A.If they have unusually frequent or severe headaches B.If they have any dizziness C.If they have any neck pain D.If they have any chest pain E.If they have any history of neck injury or surgery
A,B,C,E
To enhance the ability to visualize the fundus with an ophthalmoscope, the nurse should (select all that apply) A. Darken the room B. Have the patient focus on a distant object C. Examine the patient right eye while looking through the ophthalmoscope with his or her left eye. D. Find the red reflex in the pupil and move closer to the patient.
A,B,D
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. A.Side-to-side B.Top-to-bottom C.Posterior-to-anterior D.Interspace-by-interspace
A.Side-to-side
A client has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, at a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? A. Hypoventilation B. Cheyne-Stokes respirations C. Bradypnea D. Chronic obstructive breathing
A. Hypoventilation
A client comes to the emergency room with complaints of chest pain. When auscultating the heart, which guideline would the nurse use to identify S2? •A. S2 is louder at the base than S1. •B. S2 coincides with the carotid artery pulse. •C. S2 is louder at the apex than S1. •D. S2 coincides with the R wave on the ECG.
A. S2 is louder at the base than S1.
A nurse is assessing a client. They are concerned about their risk for heart disease and say they have been doing some reading on the internet related to it. They then ask if the nurse would explain to them what is meant by cardiac output. Which is the definition of cardiac output on which the nurse would base the response? •A. Stroke volume x Heart rate •B. Heart rate/systolic blood pressure •C. Diastolic blood pressure x cardiac cycle •D. Heart failure/Aortic pressure
A. Stroke volume x Heart rate
The nurse knows that knowledge of cardiac anatomy and physiology is essential to understanding cardiac assessment. The ___ cycle consists of rhythmic movements of systole (ventricular contraction) and diastole (relaxation). A.Cardiac B.Respiratory C.Cardiopulmonary D.Cardiovascular
A.Cardiac
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: A.Consider this a normal finding B.Refer the individual for further evaluation C.Document this as an asymmetric light reflex D.Perform the confrontation test to validate the findings
A.Consider this a normal finding
Based on your nursing assessment, you conclude that Bob has which of the following conditions? A.Peripheral artery disease B.Atherosclerosis of the carotid artery C.Coronary artery disease D.Deep vein thrombosis (DVT)
A.Deep vein thrombosis (DVT)
During an examination of a client, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear? A.Firm but freely movable B.Soft and nontender C.Unilateral D.Clumped
A.Firm but freely movable
The nurse is auscultating the client's heart. The S1 or ____ heart sound results from closure of the mitral and tricuspid valves; this sound signals the beginning of systole. A.Third B.Fourth C.First D.Second
A.First
The nurse is assessing a client's neck ROM. The nurse would correctly expect the client to be able to perform which movements with the neck? A.Flexion, hyperextension, rotation and lateral bending B.Rotation, supination, inversion, flexion C.Lateral bending, abduction, adduction, forward flexion D.Eversion, pronation, external rotation, hyperextension
A.Flexion, hyperextension, rotation and lateral bending
The nurse is palpating a client's temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the tragus. Which of the following would be a normal finding? A.Nontender to palpation B.Crepitus C.The jaw locking D.Painful palpation
A.Nontender to palpation
The nurse is assessing the client's trachea. Which of the following would be a normal finding? A.The trachea rising to midline when the client swallows B.The trachea deviating to the left when the client swallows C.The trachea deviating to the right when the client swallows D.The trachea not moving when the client swallows
A.The trachea rising to midline when the client swallows
The function of the trachea and bronchi is to: A.Transport gases between the environment and the lung parenchyma B.Condense inspired air for better gas exchange C.Moisturize air for optimum respiration D.Increase air turbulence and velocity for maximum gas transport
A.Transport gases between the environment and the lung parenchyma
Stridor is a high pitched, inspiratory crowing sound commonly associated with: A.Upper airway obstruction B.Atelectasis C.Congestive heart failure D.Pneumothroax
A.Upper airway obstruction
During a client examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? A.Using gentle pressure, palpate with both hands to compare the two sides B.Using strong pressure, palpate with both hands to compare the two sides C.Gently pinch each node between one's thumb and forefinger and move down the neck muscle D.Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern
A.Using gentle pressure, palpate with both hands to compare the two sides
A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this client is most likely experiencing: A: Intermittent Claudication. B: Sore muscles. C: Muscle cramps. D: Venousinsufficiency.
A: Intermittent Claudication.
As clients age, the arterial walls become stiffer and less compliant. Which is a consequence of this age-related change? • A. Decreased cardiac output • B. Rising systolic blood pressure • C. Decreasing diastolic blood pressure • D. Decreased pulse pressure
B. Rising systolic blood pressure
Your client is exhibiting rapid shallow breathing, with a respiratory rate > 24 respirations per minute. Which of the following conditions are they experiencing? A. Hypoxemia B. Tachypnea C. Fremitus D. Resonance
B. Tachypnea
Freshly oxygenated blood enters the heart through the ___, and is pumped out to the body through the ____. •A) Right atrium; aorta •B) Left atrium; aorta •C) Right ventricle; pulmonary arteries •D) Left ventricle; pulmonary arteries
B) Left atrium; aorta
When assessing a client the nurse is unable to palpate the left dorsalis pedis pulse. What should the nurse do first? •A) Document the finding •B) Use the doppler to assess the pulse •C) Call the physician and tell them the client has no pulse •D) Start assessing the next client
B) Use the doppler to assess the pulse
When teaching the client about the results obtained from the use of the Snellen chart, it is important to explain that: A) the smaller the denominator, the poorer the vision. B) the larger the denominator, the poorer the vision. C) the larger the numerator, the better the vision. D) the smaller the numerator, the poorer the vision.
B) the larger the denominator, the poorer the vision.
In assessing the carotid arteries of an older client with cardiovascular disease, the nurse would: •A) palpate the artery in the upper one third of the neck. •B)listen with the bell of the stethoscope to assess for bruits. •C) palpate both arteries simultaneously to compare amplitude. D) instruct client to take slow deep breaths during auscultation.
B)listen with the bell of the stethoscope to assess for bruits.
A client has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? A. Atrophied neck and trapezius muscles B. Anteroposterior-to-transverse diameter ratio of 1:1 C. Unequal chest expansion D. Increased tactile fremitus
B. Anteroposterior-to-transverse diameter ratio of 1:1
The nurse is caring for a client who reports having abdominal pain. After inspecting the client's abdomen, the nurse would be correct in performing what assessment technique? A. Light Palpation B. Auscultation C. Deep Palpation D. Percussion
B. Auscultation
You notice that this is Joe's chest shape (see image below). This is known as what? A. Deformity associated with being overweight. B. Barrel chest C. Pigeon chest D. Hypertrophy of accessory muscles used in respiration.
B. Barrel chest
You listen to Joe's chest anteriorly at the 1st and 2nd ICS at the R & L sternal borders and hear. You identify these sounds as: A. Sibilant rhonchi B. Bronchovesicular C. Vesicular D. Course rales
B. Bronchovesicular
The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check the extraocular eye muscles. The nurse knows that a healthy finding would be: A.Each eye moves in opposite directions from each other B.There is parallel tracking of the object with both eyes C.A rapid eye blink is expected D.The light reflex of the eyes is located in the same position in each eye
B.There is parallel tracking of the object with both eyes
Which statement is true regarding the arterial system? •A: Arteries are large-diameter vessels. • B: The arterial system is a high-pressure system. • C: The walls of arteries are thinner than those of the veins. • D: Arteries carry deoxygenated blood back to the heart
B: The arterial system is a high-pressure system.
The nurse is teaching the client about health promotion of the cardiovascular system. Which of the following statements would indicate a need for further teaching? •A) " I would like some information about ways to help me quit smoking." •B) "I should try to cut down on the amount of saturated fat I eat in my diet." •C) "Even though my dad had a heart attack, I don't need to get screened for heart issues earlier than anyone else." •D) " I should try to start an aerobic exercise program."
C) "Even though my dad had a heart attack, I don't need to get screened for heart issues earlier than anyone else."
The confrontation test is used to determine: A)pupillary accommodation to visual stimulation. B)the balance between the sympathetic and parasympathetic stimulation of CN III. C)gross measurement of peripheral vision. D)the degree of presbyopia present within the eye.
C)gross measurement of peripheral vision.
The nurse is auscultating a client's lungs and hears discontinuous, high-pitched, short, popping sounds heard during inspiration, and not cleared by coughing. These are described as: A. Bradypnea B. Rhonchi C. Crackles D. Wheezing
C. Crackles
The nurse is percussing over the lungs of a client with pneumonia. If the client has atelectasis, what sound will the nurse hear? A. Resonance B. Tympany C. Dullness D. Hyperresonance
C. Dullness
A palpable vibration increased with lobar pneumonia is also known as: A. Rhonchi B. Resonance C. Fremitus D. Crackles
C. Fremitus
To test the Cardinal Fields of Gaze or Diagnostic Positions Test, the nurse: A. Shines a light into the pupil of each eye and looks for the pupil of the eye to constrict. B. Has the person identify the number of fingers being held up in 2 portions of the patient's visual fields. C. Has the patient follow a moving object as the finger is moved into positions that form a star pattern (or cat-whiskers) D. Cover one eye with a card, have the person look straight ahead for 30 seconds, then remove the card & watch for movement of the eye covered by the card.
C. Has the patient follow a moving object as the finger is moved into positions that form a star pattern (or cat-whiskers)
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings? A. Increased tactile fremitus and dull percussion tones B. Adventitious sounds and limited chest expansion C. Muffled voice sounds and symmetric tactile fremitus D. Absent voice sounds and hyperresonantpercussion tones
C. Muffled voice sounds and symmetric tactile fremitus
The nurse is assessing a client's pulse bilaterally on the inside of the ankle by the medial malleolus. What is the name of the pulse the nurse is assessing? A. Femoral pulse B. Popliteal pulse C.Posterior tibial pulse D. Dorsalis pedis pulse
C. Posterior tibial pulse
The nurse is preparing to perform a Modified Allen Test. Which is an appropriate reason for this test? •A. To measure the rate of lymphatic drainage •B. To evaluate the adequacy of capillary patency before venous blood draws •C. To evaluate the adequacy of collateral circulation before cannulating the radial artery •D. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
C. To evaluate the adequacy of collateral circulation before cannulating the radial artery
A client has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? A.Absent or decreased breath sounds B.Productive cough with thin, frothy sputum C.Chest pain that is worse on deep inspiration and dyspnea D.Diffuse infiltrates with areas of dullness on percussion
C.Chest pain that is worse on deep inspiration and dyspnea
In using the ophthalmoscope to assess a client's eyes, the nurse notices a red glow in the pupils. On the basis of this finding, the nurse would: A.Suspect that there is an opacity in the lens or cornea B.Check the light source of the ophthalmoscope to verify that it is functioning C.Consider this a normal reflection of the ophthalmoscope light off the inner retina D.Continue with the ophthalmoscopicexamination and refer the patient for further evaluation
C.Consider this a normal reflection of the ophthalmoscope light off the inner retina
Which of the following terms is used to describe a decreased level of oxygen (O2) in the blood? A.Anemia B.Hypercapnia C.Hypoxemia D.Emphysema
C.Hypoxemia
Which of the following chest configurations is an exaggerated posterior curvature of the thoracic spine that is associated with aging and physical fitness? A.Scoliosis B.Barrel chest C.Kyphosis D.Pectus Excavatum
C.Kyphosis
Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position? A.Upper lobes-lateral chest B.Upper lobes-posterior chest C.Lower lobes-posterior chest D.Lower lobes-anterior chest
C.Lower lobes-posterior chest
When assessing the pupillary light reflex, the nurse should use which technique? A.Shine a penlight from directly in front of the patient and inspect for pupillary constriction. B.Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. C.Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. D.Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.
C.Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.
A client's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. A.Low gurgling; bell B.Loud, whooshing, blowing; diaphragm C.Soft, whooshing, pulsatile; bell D.High-pitched tinkling; diaphragm
C.Soft, whooshing, pulsatile; bell
The nurse is teaching a client about health promotion of the peripheral vascular system. Which statement by the client indicates a need for further teaching? •A. "I should exercise regularly and maintain a healthy weight" •B. " It is important to wear my compression stockings" •C. "I should avoid standing for prolonged periods of time" •D. "After surgery the nurse will want me to rest as much as possible"
D. "After surgery the nurse will want me to rest as much as possible"
The nurse is providing discharge instructions to a female client. Which of these statements by the client indicates understanding of abnormal assessment findings? A. "I should report sudden nipple retraction" B. "I should report my left breast being larger than the right breast" C. "I should report orange-peel skin discoloration" D. Both A and C
D. Both A and C
Next you auscultate her bowel sounds. You begin your assessment at the RLQ of the abdomen. Your rationale for doing this is that: Choose the correct response. A. Bowel sounds are more prominent at the spleen. B. Bowel sounds are more prominent at the liver. C. You want to assess each bowel sound. D. Bowel sounds are more prominent at the ileocecal valve.
D. Bowel sounds are more prominent at the ileocecal valve.
The nurse is teaching a client about risk factors for breast cancer. Which of the following is a known risk factor for breast cancer? A. low cholesterol diet B. breastfeeding an infant for more than 6 months C. Physical activity D. Menstruation before age 12 or menopause after age 55
D. Menstruation before age 12 or menopause after age 55
A 70-year-old client is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this client? A. Rasping cough, thick mucoid sputum, wheezing, and bronchitis B. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis C. Fever, dry nonproductive cough, and diminished breath sounds D. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
D. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
You check Joe's vital signs, which set would require immediate action? A. T- 100, P - 100, R- 20, BP 130/80 B. T- 99.6, P- 66, R- 16, BP 140/80 C. T- 101, P 110, R - 20, BP 110/60 D. T- 101, P- 130, R - 38, BP 140/90
D. T- 101, P- 130, R - 38, BP 140/90
The nurse is assessing a client's lower extremities and notices a weeping ulcer at the ankle. Upon further assessment the client has firm brawny edema, coarse thickened skin, but normal pulses. The client states they have aching pain that is worse at the end of the day and with prolonged sitting. Which condition does the assessment data describe? •A. Arterial insufficiency ulcer •B. Raynaud's syndrome •C. Lymphedema •D. Venous stasis ulcer
D. Venous stasis ulcer
The nurse is preparing to perform an abdominal assessment. Which of the following would help to enhance relaxation of the client's abdominal wall during the examination? A. a cool environment B. having the client place arms above the head C. examining painful areas first D. positioning the client with the knees ben
D. positioning the client with the knees ben
The nurse is assessing the pupils of a client with a pen light. Which finding would be considered normal? A.Both eyes cross when exposed to the light B.The patient's pupils are fixed and dilated in response to light C.Both pupils dilate in response to light D.Both pupils constrict in response to light
D.Both pupils constrict in response to light
When auscultating over a client's femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits: A: Are often associated with venous disease. B: Occur in the presence of lymphadenopathy. C: In the femoral arteries are caused by hypermetabolic states. D: Occur with turbulent blood flow, indicating partial occlusion.
D: Occur with turbulent blood flow, indicating partial occlusion.
During an annual physical examination, a 43-year-old client states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: a. BSEs may detect lumps that appear between mammograms. b. BSEs are unnecessary until the age of 50 years. c. She is correct—mammography is a good replacement for BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually.
a. BSEs may detect lumps that appear between mammograms.
A nurse is performing an abdominal assessment. The nurse correctly observes the following assessment findings when inspecting a client's abdomen. Select all that apply. a. Contour and symmetry b. Appearance of umbilicus c. Skin color d. Demeanor e.Pulsation or movement
a. Contour and symmetry b. Appearance of umbilicus c. Skin color d. Demeanor e.Pulsation or movement
The nurse is assessing a client's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation by displaying the breast against the chest wall? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders
a. Supine with the arms raised over her head
The nurse is assessing a client's abdomen. She places the diaphragm of the stethoscope in the area where bowel sounds are prominent which is: a. The RLQ of the abdomen b. The RUQ of the abdomen c. The LUQ of the abdomen d. The LLQ of the abdomen
a. The RLQ of the abdomen
During a breast health assessment, the client states that she has noticed pain in her left breast. An appropriate response to this by the nurse would be: a."Don't worry about the pain; breast cancer is not painful." b. "I would like some more information about the pain in your left breast." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "Breast pain is almost always the result of benign breast disease."
b. "I would like some more information about the pain in your left breast."
During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. The nurse understands that before reporting this finding as "absent bowel sounds" it is important to listen for at least _____ in each quadrant. a. 1 minute. b. 5 minutes. c. 10 minutes. d. 2 minutes.
b. 5 minutes.
A client comes to the clinic with what he calls a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. Which of the following statements is true? a. Breast masses in men are difficult to detect because of minimal breast tissue. b. Gynecomastia is a benign growth of the breast tissue. c. Breast cancer is more likely to occur in men than women. d. Gynecomastia is an enlarged cancerous nodule located in the breast tissue.
b. Gynecomastia is a benign growth of the breast tissue.
The nurse is preparing to examine a client who reports right lower abdominal pain. The nurse's best action would be to: a. Palpate the tender area first. b. Palpate the tender area last. c. Avoid palpating the tender area. d. Notify the physician.
b. Palpate the tender area last.
The nurse is performing percussion by tapping on a client's abdomen in the left upper quadrant (spleen) and right upper quadrant (liver). Which of the following would be an expected assessment finding in these two areas of the GI system? a.Resonance b.Dullness c.Tympany d.Hyperresonance
b.Dullness
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: a.The largest quadrant of the breast. b.The location of most breast tumors. c.Where most of the suspensory ligaments attach. d.More prone to injury and calcifications than other locations in the breast.
b.The location of most breast tumors.
The nurse is educating a client on breast self-examination (BSE). Which of these statements by the client indicates understanding of the proper BSE technique? a."The best time to perform the BSE is in the middle of my menstrual cycle." b."A woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue." c. "The best time to perform the BSE is 4 to 7 days after the first day of my menstrual cycle." d."I do not need to perform a BSE until after my baby is born."
c. "The best time to perform the BSE is 4 to 7 days after the first day of my menstrual cycle."
During an examination of a client, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Breasts should always be symmetric. b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. c. Asymmetry is not unusual, but the nurse should verify that this change is not new. d. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.
c. Asymmetry is not unusual, but the nurse should verify that this change is not new.
During the physical examination, the nurse notices that the client has an inverted left nipple. Which statement regarding this is most accurate? a.Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. The nurse should determine whether the inversion is a recent change. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
c. The nurse should determine whether the inversion is a recent change.
The nurse is palpating a client's breasts during a seated examination. She notes the client has large pendulous breasts. What is the most appropriate course of action for the nurse to take? a. Have a physician perform the assessment b. Have another nurse continue the assessment c. Use the bimanual technique to perform the assessment d. Refer the client for a breast scan
c. Use the bimanual technique to perform the assessment
A nurse is performing an assessment on a client. Which of the following statements demonstrates her understanding of the rationale for correct sequencing for an abdominal assessment? a. "It is important to sequence the exam to prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation." b. "It is important to sequence the exam to determine areas of tenderness before using percussion and palpation." c."It is important to sequence the exam to avoid distorting the client's bowel sounds." d. "It is important to sequence the exam to allow the client more time to relax and be more comfortable with the physical examination."
c."It is important to sequence the exam to avoid distorting the client's bowel sounds."
Next is percussion of the client's abdomen.Fill in the blank: The expected sound that should be noted over the abdomen is and over the liver and spleen. a.Tympany, resonance b.Tympany, hypersonance c.Tympany, dullness d.Tympany, tympany
c.Tympany, dullness
The nurse is teaching a client about health promotion of the gastrointestinal system. Which of the following statements would indicate a need for further teaching? a. "I should try to drink at least 8 glasses of water daily." b. "I should try to avoid having high fatty foods in my diet." c. "I plan to exercise more so I can maintain a healthy weight." d. "The amount of alcohol I have should not affect my health if I dilute it with water."
d. "The amount of alcohol I have should not affect my health if I dilute it with water."
The nurse is caring for a client who reports having abdominal pain. After inspecting the client's abdomen, the nurse would be correct in performing what assessment technique? a. Deep palpation b. Percussion c. Light palpation d. Auscultation
d. Auscultation
The nurse is aware that one change that may occur in the gastrointestinal system of an aging client is: a. Increased salivation. b. Increased liver size. c. Increased esophageal emptying. d. Decreased gastric acid secretion.
d. Decreased gastric acid secretion.
The nurse is teaching a client about risk factors for breast cancer. She correctly includes which of the following risk factors? a. Breastfeeding an infant for more than 6 months. b. A low cholesterol diet. c. Physical activity. d. Menstruation before age 12 or menopause after age 55.
d. Menstruation before age 12 or menopause after age 55.
A nurse is performing a client assessment. Which of these clinical situations, if noted, should the nurse consider to be outside normal limits? a. The client has had one pregnancy. Her breast examination reveals breasts that are soft and slightly sagging. b. The client has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. The client has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is somewhat engorged. She states that the examination was slightly painful. d. The client has had two pregnancies. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
d. The client has had two pregnancies. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
A nurse is performing an assessment on a client who reports abdominal pain. Which of the following actions should the nurse implement to promote relaxation of the client's abdomen during the assessment? a.Position the client supine, with the knees bent. b.Examine the painful areas first. c.Distract the client. d.Both a and c
d.Both a and c
The nurse is assessing a client's peripheral vascular and lymphatic system. Which of the following are general principles the nurse should use when assessing these systems? (Select all that apply.) •A. Inspect for color •B. Palpate for capillary refill •C. Ensure the room temperature is cold •D. Measure extremities if uncertain about symmetry of size •E. Assess limbs unilaterally
•A, B, D.
When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: •A) mitral and tricuspid. •B) tricuspid and aortic. •C) aortic and pulmonic. •D) mitral and pulmonic.
•C) aortic and pulmonic.
