health assessment exam 3
How many chambers are in the heart?
4 (2 atria, 2 ventricles)
Development of visible signs of pressure can be delayed. Events leading to a pressure that could cause an injury could occur up to how many hours before a visible change is seen?
48 hrs
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least: a. 1 minute b. 5 minutes c. 10 minutes d. 2 minutes in each quadrant
5 minutes
A 40-year-old man states that his physician diagnosed him with a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. "No need to worry. Most men your age develop hernias." b. "A hernia is a loop of bowel that has pushed through a weak spot in the abdominal muscles." c. "A hernia is the result of prenatal growth abnormalities that are just now causing problems." d. "I'll have to have your physician explain this to you."
"A hernia is a loop of bowel that has pushed through a weak spot in the abdominal muscles."
The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
"Auscultation prior prevents distortion of bowel sounds that might occur after percussion and palpation."
The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?
"The flow of lymph is slow compared with that of the blood."
aging adult abdominal changes
- abdominal wall musculature relaxes - salvation decreases= leading to dry mouth and decreased sense of taste -gastric acid secretion is delayed - incidence of gallstones increase - liver size decreases
The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds:
Are usually high-pitched, gurgling, and irregular sounds
For a patient with darker skin it can be difficult to evaluate jaundice. as it may only present as a subtle discoloration. One of the ways to assess this patient could be to look at the whites of their eyes. What would be a good alternative way to evaluate jaundice for this patient?
Ask family members if they feel the patient 's skin is a different color than usual
When inspecting a patient's abdomen, the nurse notes an old surgical scar at midline extending vertically below the umbilicus. The nurse will: (Select all that apply.) a. Not be concerned with it because it is an old scar. b. Ask the patient about the scar. c. Not consider it relevant because the patient did not identify it. d. Include a drawing of the scar's location on the abdomen in the documentation. e. Measure and record the length of the scar in the documentation.
Ask the patient about the scar, include a drawing of the scar's location on the abdomen in the documentation, and Measure and record the length of the scar in the documentation.
Natural light is ideal for doing skin assessments however sometimes we are limited to access of natural light and need to use the florescent lights widely used in hospitals and clinics. Why are florescent lights not ideal lighting for examining a patient with darkly pigmented skin?
Because florescent light casts a blue tone on darkly pigmented skin
When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?
Blood can flow into the left side of the heart through an opening in the atrial septum.
What do bowel sounds sound like?
Bowel sounds are high pitched, gurgling, cascading sounds,occurring irregularly anywhere from 5 to 30 times per minute
right lower quadrant organs
CECUM APPENDIX RIGHT OVARY AND TUBE RIGHT URETER RIGHT SPERMATIC CORD
A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:
Dysphagia
the findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
Elevated pressure related to heart failure
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
Enlarged and tender inguinal nodes
When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? a. Assess the patients abdomen, and notice any tenderness. b. Carefully assess the cervical lymph nodes, and check for any enlargement. c. Ask additional health history questions regarding any recent ear infections or sore throats. d. Examine the patients lower arm and hand, and check for the presence of infection or lesions.
Examine the patients lower arm and hand, and check for the presence of infection or lesions.
During inspection of a 52-year-old patient, the nurse notes that the patient's abdomen is bulging and stretched with dullness percussed to the left lower quadrant. The nurse will document that the patient:
Has a protuberant abdomen, which requires further investigation
peristalsis
Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.
right upper quadrant organs
LIVER GALLBLADDER DUODENUM HEAD OF PANCREAS RIGHT KIDNEY AND ADRENAL GLAND HEPATIC FLEXURE OF COLON PART OF ASCENDING AND TRANSVERSE COLON
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
Lateral to the extensor tendon of the great toe
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: a.) Rubeola. b.) Lyme disease. c.) Allergy to mosquito bites. d.) Rocky Mountain spotted fever.
Lyme disease
Ecchymosis or bruising can be harder to detect on patients with darker skin tones and you as the nurse could have to wait until the bruises got darker and were more visible. Why is new bruising hard to see on darker pigmented skin?
New bruising may appear pink and therefore difficult to see on darker skin tones
While examining a patient, the nurse observes abdominal pulsations between the xiphoid
Normal abdominal aortic pulsations
left lower quadrant organs
PART OF DESCENDING COLON SIGMOID COLON LEFT OVARY AND TUBE LEFT URETER LEFT SPERMATIC CORD
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
Percuss and palpate the midline area above the suprapubic bone
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
Peritonitis
The direction of blood flow through the heart is best described by which of these?
Right atrium > right ventricle > pulmonary artery > lungs > pulmonary vein > left atrium > left ventricle
The electrical stimulus of the cardiac cycle follows which sequence?
SA node > AV node > bundle of His > bundle branches
left upper quadrant organs
SPLEEN STOMACH LEFT LOBE OF LIVER BODY OF PANCREAS LEFT KIDNEY AND ADRENAL GLAND SPLENIC FLEXURE OF COLON PART OF TRANSVERSE AND DESCENDING COLON
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?
Smoking, hypertension, obesity, diabetes, and high cholesterol
Which statement is true regarding the arterial system?
The arterial system is a high-pressure system.
The nurse is reviewing the anatomy and physiological functioning of the heart. Which statement best describes what is meant by atrial kick?
The atria contract toward the end of diastole and push the remaining blood into the ventricles.
lactose intolerance
The inability to completely digest the milk sugar lactose
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?
The presence of palpable lymph nodes
Which of these statements describes the closure of the valves in a normal cardiac cycle?
The tricuspid valve closes slightly later than the mitral valve.
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination findings, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
This decline in blood pressure is the result of peripheral vasodilatation and is an expected change.
The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication
a person who has been on bed rest for 4 days
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat
an increased loss of elastin and a decrease in subcutaneous fat
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
aortic and pulmonic
The next stop on your trip means that you have to exit the heart... what valve needs to open to allow you to exit the heart?
aortic valve
You flowed through the mitral valve perfectly!!! you are now in the left ventricle getting ready to jump into the blood flow in the Aorta. But how do you get out of the heart? Its easy really, you just exit via the...?
aortic valve
During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? a. Spleen b. Sigmoid c. Appendix d. Gallbladder
appendix
During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. Splenomegaly b. Distended bladder c. Constipation d. Ascites
ascites
A patient of African origin is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue b. Generalized pallor c. Ashen, grey, or dull d. Patchy areas of pallor
ashen, grey or dull
celiac disease
autoimmune disorder, intolerant of gluten
14. During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line d. Dull percussion note in the left upper quadrant at the midclavicular line
b. Tympanic percussion note in the umbilical region
A 62-year-old patient with heart failure comes to the clinic for his annual examination. During skin assessment, the nurse notes slight swelling to the patient's feet, and indentations which quickly fade when both feet are palpated. The nurse will chart this finding as: a. No edema noted. b. Unilateral deep pitting 3+ edema. c. Bilateral moderate pitting 2+ edema. d. Mild pitting 1+ edema.
bilateral moderate pitting 2+ edema
The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.
brachial
When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:
bruits occur with turbulent blood flow, indicating partial occlusion.
Erythema is the reddened appearance of skin and is associated with inflammation and infection. It can be difficult to assess with patients who have a darker skin tone. For patients with darker skin, what color skin tone, what color other than a normal reddened area would you look for?
burgundy
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a.) Polycythemia. b.) Carbon monoxide poisoning. c.) Carotenemia. d.) Uremia.
carbon monoxide poisoning
A patient is especially worried about the white coloration of an area of skin on her feet, and she has been told it is vitiligo. The nurse explains that vitiligo is: a. Caused by an excess of melanin pigment. b. Caused by an excess of apocrine glands in her feet. c. Caused by the complete absence of melanin pigment. d. Related to impetigo and can be treated with an ointment.
caused by the complete absence of melanin pigment
20. During abdominal assessment, the nurse performs deep palpation to screen for: a. Bowel motility b. Changes in size of organs c. Gastroesophageal reflux d. Abdominal skin and musculature
changes in size of organs
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse notes: a. Anasarca. b. Scleroderma. c. Pedal erythema. d. Clubbing of the nails.
clubbing of the nails
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a.) "Signs of decreased hematocrit related to anemia." b.) "Due to the destruction of melanin in your skin from exposure to the sun." c.) "Clusters of melanocytes that appear after extensive sun exposure." d.) "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."
clusters of melanocytes that appear after extensive sun exposure
When a patient has keloid scarring, one of the things that may contribute to the formation of the scar is an overproduction of what?
collagen
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Colour variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm
color variation
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a __________ profile.
concave
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _________profile. a. Flat b. Convex с. Bulgingd. Concave
concave
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors
contains sensory receptors
17. An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion b. Decreased gastric acid secretion c. Delayed gastrointestinal emptying time d. Increased gastrointestinal emptying time
decreased gastric acid secretion
The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:
decreased gastric acid secretion
The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a. Increased salivation. b. Increased liver size. с. Increased esophageal emptying. d. Decreased gastric acid secretion.
decreased gastric acid secretion
common causes of constipation
decreased physical activity, inadequate intake of water, low fiber diet, side effects of meds, IBS, bowel obstruction, hypothyroidism
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
dullness
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Тympany с. Resonance d. Hyperresonance
dullness
Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the RUQ c. Hyper-resonance in the left upper quadrant d. Tympany in the right and left lower quadrants
dullness across the abdomen
During the health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" On the basis of these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis
duodenal ulcer
The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.
eccrine glands
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first b. Examine the tender area last c. Avoid palpating the tender area d. Palpate the tender area first and then auscultate for bowel sounds
examine the tender area last
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition results from hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood. b. Excess blood in the underlying blood vessels. c. Decreased perfusion to the surrounding tissues. d. Excess blood in the dilated superficial capillaries.
excess blood in the dilated superficial capillaries
The nurse is assessing a 60-year-old male patient with sharp upper abdominal pain. What additional finding during history taking indicates possible peptic ulcer disease? a. Lactose intolerance b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs)
frequent use of non steroidal anti-inflammatory drugs
21. The nurse notices that a patient has black, tarry stools and recognizes that they could indicate: a. Gallbladder disease b. Iron supplementation c. Gastrointestinal bleeding d. Localized bleeding around the anus
gastrointestinal bleeding
Cyanosis refers to a specific change in color of the skin and mucous membranes. This condition may be caused by inadequate oxygenation. The best place to look for peripheral cyanosis would be where on the body?
hands and feet
pyrosis
heartburn; burning sensation in upper abdomen due to reflux of gastric acid
Patients with darkly pigmented skin have _____________ rates of full thickness pressure injuries as compared to patients with lighter skin.
higher
The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. Loud continual hum. b. Peritoneal friction rub. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds
hyperactive bowel sounds
A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a.) Eczema. b.) Impetigo. c.) Herpes zoster. d.) Diaper dermatitis.
impetigo
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the health history interview, the patient informs the nurse that she takes an oral hypoglycemic medication for diabetes. The nurse provides teaching about the medication and: a. Increased possibility of bruising. b. Skin sensitivity as a result of exposure to salt water. c. Lack of availability of glucose-monitoring supplies. d. Importance of sunscreen and avoiding direct sunlight.
importance of sunscreen and avoiding direct sunlight
The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for heart disease? (Select all that apply. a. Ethnicity b. Increased low-density lipoproteins c. Smoking d. Gender e. Hypertension f. Diabetes g. Family history
increased low density lipoproteins, smoking, hypertension, diabetes
The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
intraluminal valves ensure unidirectional flow toward heart
A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should inform her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.
is caused by increased sebum production
A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _______ the left leg. a. Venous obstruction of b. Claudication due to venous abnormalities in c. Ischemia caused by a partial blockage of an artery supplying d. Ischemia caused by the complete blockage of an artery supplying
ischemia caused by a partial blockage of an artery supplying
During a skin assessment, the nurse initially is concerned that the patient who is of East Asian origin has skin that is yellowish-brown. On further assessment, the nurse notes that the skin on the hard and soft palate is pink and the patient's sclerae are not yellow. From this finding, the nurse recognizes that the patient likely does not have: a. Pallor. b. Jaundice. c. Cyanosis. d. Iron deficiency
jaundice
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a.) Measles (rubeola). b.) Kaposi's sarcoma. c.) Angiomas. d.) Herpes zoster.
kaposis sarcoma
18. A patient is complaining of a sharp pain along the costovertebral angle. The nurse is aware that this symptom is most often indicative of: a. Ovary infection b. Liver enlargement c. Kidney inflammation d. Spleen enlargement
kidney inflammation
The 22-year-old patient informs the nurse she feels bloated and has diarrhea when she drinks milkshakes and eats ice cream. The nurse recognizes this as possible: a. Celiac disease b. Lactose intolerance c. Cholecystitis d. Wheat allergy
lactose intolerance
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe
lateral to the extensor tendon of the great toe
You take a quick trip through the Pulmonary veins and head back to the heart...where do you enter the heart?
left atria
The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a.) Lesions that run together. b.) Annular lesions that have grown together. c.) Lesions arranged in a line along a nerve route. d.) Lesions that are grouped or clustered together.
lesions that run together
A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a.) A keloid. b.) A fissure. c.) Keratosis. d.) Lichenification.
lichenification
During the aging process, the hair can look grey or white and begin to feel thin and fine. the nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c. Phagocytes. d. Melanocytes.
melanocytes
When doing a skin assessment on darkly pigmented skin, the skin is often thicker and drier than more lightly colored skin and the skin may appear ashen. To help get a better idea of what color the skin is, the nurse could do what?
moisten the skin
he nurse is assessing for clubbing of the fingernails and expects to find: a.) Nail bases that are firm and slightly tender. b.) Curved nails with a convex profile and ridges across the nails. c.) Nail bases that feel spongy with an angle of the nail base of 150 degrees. d.) Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy
nail bases with an angle of 180 degrees or greater and nail bases that feel spongey
While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: a. Pulsations of the renal arteries. b. Pulsations of the inferior vena cava. с. Normal abdominal aortic pulsations. d. Increased peristalsis from a bowel obstruction.
normal abdominal aortic pulsations
The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:
normal for this age
The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a.) Assessing the skin for cyanosis and swelling b.) Assessing the oral mucosa for generalized erythema c.) Palpating the skin for edema and increased warmth d.) Palpating for tenderness and local areas of ecchymosis
palpating the skin for edema and increased warmth
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a.) Bulla. b.) Wheal. c.) Nodule. d.) Papule.
papule
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region. b. Inspect and palpate in the epigastric region. c. Auscultate and percuss in the inguinal region. d. Percuss and palpate the midline area above the suprapubic bone.
percuss and palpate midline area above the suprapubic bone
When assessing a patient's cardiovascular system, the nurse notes a high-pitched scratchy sound at the apex of the heart. The nurse recognizes this as rubbing between the two walls of the sac surrounding and protecting the heart called the:
pericardium
A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.
peripheral vasoconstriction
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a. Diarrhea. b. Peritonitis. с. Laxative use. d. Gastroenteritis.
peritonitis
The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?
person who has been on bed rest for 4 days
While assessing a patient's skin, the nurse notes multiple skin fissures on the hands. The nurse recognizes this as: a. Diaphoresis in the patient. b. Potential openings for bacterial infection. c. Poor temperature regulation. d. Impaired perception to pain.
potential openings for bacterial infection
24. During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by: a. Projectile vomiting b. Hypoactive bowel activity c. Palpable olive-sized mass in the right lower quadrant d. Pronounced peristaltic waves crossing from right to left
projectile vomitting
A patients abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. Obese. b. Herniated. c. Scaphoid. d. Protuberant.
protuberant
As a red blood cell you need oxygen! You need to head to the lungs to pick up some 02! What takes you to the lungs from the right side of the heart?
pulmonary artery
You are now in the lungs! You made it... absorb all the 02 that you can and head back to the heart! You need exit the lungs via the...?
pulmonary veins
15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea b. Pyrosis c. Dysphagia d. Constipation
pyrosis
25. To detect diastasis recti, the nurse should ask the patient to perform which of these manoeuvres? a. Relaxing in the supine position b. Raising the arms in the left lateral position c. Raising the arms over the head while in a supine position d. Raising the head while in the supine position
raising the head while in supine position
Deep tissue pressure injuries (DPTI) can present with a variability of colors. Which of the following colors are not often associated with DPTI in patients with darkly pigmented skin?
red
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks.
replaced every 4 weeks
During abdominal assessment of an adult patient, the nurse auscultates a bruit in the upper abdomen area just left of the midline. The nurse will: a. Palpate the area b. Document the findings as normal c. Report the findings immediately d. Assess for rebound tenderness
report the findings immediately
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a.) Senile lentigines, which do not become cancerous b.) Actinic keratoses, which are precursors to basal cell carcinoma c.) Acrochordons, which are precursors to squamous cell carcinoma d.) Seborrheic keratoses, which do not become cancerous
seborrheic ketoses, which do not become cancerous
A 42-year-old woman is concerned about several small, slightly raised, bright red dots that have appeared on her chest. On examination, the nurse explains that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.
senile angiomas
2. Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum с. Gallbladder d. Sigmoid colon
sigmoid colon
When percussing the left lower quadrant of the abdomen, the nurse elicits a drumlike sound normal for the:
sigmoid colon
The component of the conduction system referred to as the pacemaker of the heart is the:
sinoatrial node
When palpating the abdomen of a 20-year-old patient who was injured in a motor vehicle accident, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder
spleen
Which of these veins are responsible for most of the venous return in the arm?
superficial
Which vein(s) is(are) responsible for most of the venous return in the arm? a. Deep b. Ulnar c. Subclavian d. Superficial
superficial
The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply.) a. Test for Murphy's sign b. Test for Blumberg's sign c. Test for shifting dullness d. Perform the iliopsoas muscle test e. Test for fluid wave
test for blumbergs sign, test for fluid wave
A patient is suspected of having cholecystitis, or inflammation of the gallbladder. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b. Test for inspiratory arrest c. Assess for rebound tenderness d. Iliopsoas muscle test
test for inspiratory arrest
A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which class of medications? a. Nonsteroidal anti-inflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism
tetracyclines for acne
Which of these statements is true regarding the arterial system?
the arterial system is a high-pressure system.
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.
the newborn's skin is more permeable than that of the adult
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, What happens to my circulation when this vein is removed? The nurse should reply: Venous insufficiency is a common problem after this type of surgery. b. Oh, you have lots of veinsyou wont even notice that it has been removed. c. You will probably experience decreased circulation after the vein is removed. d. This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition.
this vein can be removed without harming your circulation because the deeper veins in your leg are in good condition
After you travel through the tricuspid valve, where would you go next?
to the right ventricle
You are a red blood cell... and now that you are in the Right Atria, where do you go next?
tricuspid valve
The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds: a. Are usually loud, high-pitched, rushing, and tinkling sounds. b. Are usually high-pitched, gurgling, and irregular sounds. с. Sound like two pieces of leather being rubbed together. d. Originate from the movement of air and fluid through the large intestine.
usually high-pitched, gurgling, and irregular sounds
During an examination, the nurse finds that a patient has excessive dryness of the skin. When charting, the nurse describes this condition as: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.
xerosis
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a.) Yellow patches in the outer sclera b.) Yellow color of the sclera that extends up to the iris c.) Skin that appears yellow when examined under low light d.) Yellow deposits on the palms and soles of the feet where jaundice first appears
yellow color of the sclera that extends up to the iris
