Health Assessment Quiz #2
TRUE OR FALSE: Contractility decreases when stimulated by the sympathetic nervous system.
FALSE
TRUE OR FALSE: Each electrical impulse is initiated in the AV node.
FALSE
TRUE OR FALSE: Hepatitis B is transmitted by the fecal-oral route.
FALSE
TRUE OR FALSE: Paraplegia is paralysis of all four limbs.
FALSE
TRUE OR FALSE: Pulsus alternans almost always indicates severe right-sided heart failure.
FALSE
TRUE OR FALSE: Transmission of hepatitis A is by repeated percutaneous exposure to blood.
FALSE
__________ are rope-like bundles of collagen fibrils that connect bone to bone.
Ligaments
__________ refers to enlargement of the nodes, with or without tenderness.
Lymphadenopathy
__________ refers to urinary frequency at night.
Nocturia
__________ is the period of ventricular contraction.
Systole
TRUE OR FALSE: A protuberant abdomen that is tympanic throughout suggests intestinal obstruction.
TRUE
TRUE OR FALSE: An exaggerated, widened femoral pulse suggests a femoral aneurysm.
TRUE
TRUE OR FALSE: Ergonomic furniture may reduce the effects of prolonged flexion of the legs.
TRUE
TRUE OR FALSE: In deep vein thrombosis, the extent of edema suggests the location of the occlusion.
TRUE
TRUE OR FALSE: Jugular venous pressure (JVP) reflects right atrial pressure.
TRUE
TRUE OR FALSE: Poor compliance produces a stiff ventricle with reduced ability to expand as it receives blood.
TRUE
TRUE OR FALSE: Prostatic pain may be felt in the perineum and occasionally in the rectum.
TRUE
TRUE OR FALSE: Research has found that the Homan sign is unreliable as an assessment for deep vein thrombosis.
TRUE
TRUE OR FALSE: Restricted abduction is common in hip osteoarthritis.
TRUE
TRUE OR FALSE: Sciatic nerve tenderness suggests a herniated disc or mass lesion impinging on the contributing nerve roots.
TRUE
TRUE OR FALSE: Stroke volume is the amount of blood ejected by the ventricle with each heartbeat.
TRUE
TRUE OR FALSE: The bladder normally cannot be examined unless it is distended about the symphysis pubis.
TRUE
TRUE OR FALSE: The principal muscles opening the mouth are the external pterygoids.
TRUE
TRUE OR FALSE: The quadriceps is the strongest muscle in the body.
TRUE
TRUE OR FALSE: The radial pulse is palpated over the lateral flexor surface.
TRUE
Which of the following are functions of the GI tract? (select all that apply) a. digestion of food b. elimination of waste c. provision of oxygen to the organs d. circulation of blood e. production of lymphocytes to fight infection
a and b
Which of the following should the nurse include when documenting objective findings? (select all that apply) a. vital signs b. inspection results c. reason for client encounter d. plan of care e. patient teaching
a and b
Which of the following findings are unexpected when inspecting the abdomen? a. soft protrusion of the umbilicus b. silver white striae c. scaphoid abdomen d. voluntary guarding e. prominent veins
a and e
Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply. a. Overweight b. Smoking c. Lack of exercise d. Ethnicity e. Family history
a, b, and c
Which of the following are signs for peripheral artery disease? (select all that apply) a. ulcer on the toes b. leg pain that occurs with activity c. decreased or absent pulses d. warm skin temperature e. a bleeding ulceration on legs
a, b, and c
Which of the following maneuvers should you assess during ROM of the spine? a. lateral flexion b. hyperextension c. opposition d. rotation e. supination
a, b, and d
Which of the following client responses require the nurse to ask additional open-ended questions? (select all that apply) a. "I feel so tired even just to put out the trash" b. "I used to be able to walk every day, but lately it's been too hard" c. "Never a smoker. I like to have a beer occasionally, but that's it" d. "I slipped and fell last year on an icy step but I didn't get hurt" e. "Now that you mention it, I did have some chest pain yesterday when I was cleaning. I had to sit down and rest for awhile"
a, b, and e
Which of the following are risk factors for heart disease? (select all that apply) a. BMI > 30 b. smoking tobacco c. aerobic exercise d. family history of hypertension e. type II diabetes
a, b, d, and e
A client is being discharged home from the hospital. This client has a history of falling at home. A caregiver is not able to stay with the client all the time. What can be done to decrease the risk for falling at the client's home? Select all that apply. a. Install grab bars in the bathroom b. Place colorful throw rugs near the exits c. Correct environmental hazards in the home d. Make sure house hallways are well lit e. Have the client go to a physical therapy three times a week
a, c, and d
Which of the following client responses require the nurse to ask additional open-ended questions? (select all that apply) a. "I've thrown up three times today and I feel awful. My stomach is so queasy and it hurts" b. "I feel a little warm. I think I have a fever. I also have body aches and pains" c. "For lunch yesterday I at a salad that I made from the salad bar at the grocery store. I went out to dinner last night and ordered shrimp scampi" d. "Now that I think about it, a coworker called in sick yesterday because she had the flu. I was surprised because she didn't seem sick the day before yesterday" e. "No one who I had lunch or dinner with yesterday is sick"
a, c, and d
The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply. a. Increased cardiac output b. Decreased cardiac output c. Increased blood pressure d. Decreased blood pressure e. Increased heart rate
a, c, and e
Which of the following foods promote bone health? a. egg yolks b. orange slices c. salmon d. yogurt e. broccoli
a, c, d, and e
A client with heart disease is a current cigarette smoker. What should the nurse include when caring for this client? Select all that apply. a. Assist with finding resources b. Acknowledge dependence c. Arrange for follow-up d. Assess willingness to quit e. Advise to quit
a, c, d, and e (the five A's)
Which of the following are nursing interventions for chest pain? (select all that apply) a. apply oxygen b. monitor vital signs every 4 hours c. encourage the client to ambulate d. provide continuous ECG monitoring e. obtain IV access
a, d, and e
What is the correlating scale rating for mild pitting edema that is barely noticeable? a. +1 b. +2 c. +3 d. +4
a. +1
How would the nurse document normal muscle strength? a. 5/5 b. 1:1 c. 2 & 2 d. 4+
a. 5/5
A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen? a. Absent b. Hyperactive c. Borborygmus d. Erratic
a. Absent
A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition? a. Ankle-brachial index (ABI) b. CT scan of the lower legs c. PET scan d. Venogram
a. Ankle-brachial index (ABI)
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? a. Appendicitis b. Inflammation of the gallbladder c. Kidney pain d. Liver engorgement
a. Appendicitis
An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. What would the nurse suspect? a. Arterial insufficiency b. Venous insufficiency c. Musculoskeletal weakness d. Diabetic neuropathy
a. Arterial insufficiency
A nurse assesses the peripheral vascular system of a client who is in the supine position. What further assessment should the nurse perform if unable to palpate the left popliteal pulse? a. Assist the client to the prone position and palpate again. b. Palpate the right leg with the client in supine position. c. Place the client in the lateral position and palpate. d. Elevate and palpate the left leg in supine position.
a. Assist the client to the prone position and palpate again.
When performing a nursing assessment, which assessment technique should the nurse begin after inspecting the abdomen? a. Auscultation b. Olfaction c. Palpation d. Percussion
a. Auscultation
When assessing temperature of the skin, which portion of the hand should the examiner use? a. Backs of fingers b. Ulnar aspect of the hand c. Palms d. Fingertips
a. Backs of fingers
Mark is a contractor who recently injured his back. He was told he had a "bulging disc" to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint? a. Cartilaginous b. Synovial c. Synostosis d. Fibrous
a. Cartilaginous
The client is the pitcher of the high school baseball team. He is brought to the clinic by his mother with a complaint of pain in his right elbow. Where would the nurse expect to locate his tenderness? a. Distal to the right medial epicondyle b. Proximal to the right olecranon bursa c. Distal to the right lateral epicondyle d. Over the right olecranon process
a. Distal to the right medial epicondyle
A 46-year-old former salesman presents to the ER complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. Examination shows a man appearing older than his stated age. His skin has a yellowish tint and he is thin with a prominent abdomen. Multiple "spider angiomas" are at the base of his neck. Otherwise his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs? a. Esophageal varices b. Infectious diarrhea c. Mallory-Weiss tear
a. Esophageal varices
A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what? a. Flat neck veins b. Invisible neck veins c. Round neck veins d. Distended neck veins
a. Flat neck veins
During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following? a. Heart attacks in his father and siblings b. Hypertension in his grandparents c. Diabetes mellitus in his extended family d. Weight patterns within his family
a. Heart attacks in his father and siblings
A 23-year-old man has recently graduated from university and is preparing to embark on a backpacking trip around Southeast Asia. In preparation for his trip, the client has visited a clinic to obtain vaccinations. The client will be able to obtain vaccines protecting against which of the following? a. Hepatitis A and B b. Hepatitis C c. Hepatitis A d. Hepatitis B and C
a. Hepatitis A and B
When auscultating the heart, your first step is to: a. Identify S1 and S 2 b. Listen for S3 and S4 c. Listen for murmurs d. Identify all four sounds on the first round
a. Identify S1 and S 2
Which of the following client responses requires you to ask additional open-ended questions? a. It's my left knee and I feel like its been forever that it's been hurting b. Yes I think so. My left knee now makes this clicking sound when I walk and sometimes it gets quite swollen. Just like my right knee did before I had a total knee replacement. c. Oh I'd give my pain a 7. I take ibuprofen every 6 hours and put ice on my knee to help the pain d. Yes a few weeks ago. I caught myself and landed on all fours. I think the dog got under my feet.
a. It's my left knee and I feel like its been forever that it's been hurting
A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following? a. Pacemaker b. Conduction system c. Bundle of His d. Purkinje fibers
a. Pacemaker
Assessment reveals that an older adult client has osteomalacia. What would be most important to include in the client's teaching plan? a. Practice risk prevention for fractures. b. Minimize movements to maintain joint stability. c. Treat secondary arthritis proactively. d. Keep exercise to a minimum to decrease pain.
a. Practice risk prevention for fractures.
Which of the following documentation provides the most accurate information to include in the medical record? a. Radial pulses +1 bilaterally with rate 110 bpm b. Radial pulse strong c. Radial pulse present bilaterally d. Radial pulse +2
a. Radial pulses +1 bilaterally with rate 110 bpm
When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant? a. Right kidney, ascending colon, and liver b. Right ovary, descending colon, and spleen c. Right kidney, transverse colon, and inguinal ligament d. Right ovary, pancreas, and sigmoid colon
a. Right kidney, ascending colon, and liver
Diagnostic tests completed validate that a client has an obstruction of the ascending and transverse colon. Where should the nurse assess for bowel sounds around the obstruction? a. Right upper quadrant b. Left upper quadrant c. Left lower quadrant d. Right lower quadrant
a. Right upper quadrant
The school nurse notes that the client carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem? a. Scoliosis b. Dislocated shoulder c. Torn rotator cuff d. Broken clavicle
a. Scoliosis
A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant? a. Spleen b. Gallbladder c. Liver d. Head of pancreas
a. Spleen
A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history? a. The left lower quadrant is palpated last b. Encourage the client to relax to minimize pain c. This area should be avoided completely d. Medicate for pain before beginning the assessment
a. The left lower quadrant is palpated last
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next? a. Use Doppler ultrasonography to locate the pulse. b. Ask another nurse to assess the pulse. c. Auscultate the anatomic area with a stethoscope. d. Document absence of dorsalis pedis pulse.
a. Use Doppler ultrasonography to locate the pulse.
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following? a. Venous insufficiency b. Dependent edema c. Stasis ulceration d. Arterial occlusion
a. Venous insufficiency
Which of the following is an abnormal finding that should be documented and reported to the provider? a. abdominal distention b. silver striae c. abdominal symmetry d. borborygmus
a. abdominal distention
While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for a. arthritis. b. nerve damage. c. carpal tunnel syndrome. d. ganglion cyst.
a. arthritis.
The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should a. ask the client to empty his bladder. b. tell the client to raise his arms above his head. c. place the client in a side-lying position. d. ask the client to hold his breath for a few seconds.
a. ask the client to empty his bladder.
An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to a. gouty arthritis. b. bone fractures. c. osteomalacia. d. osteomyelitis.
a. gouty arthritis.
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for a. lymphedema. b. Raynaud disease. c. bruits over the radial artery. d. poor peripheral pulses
a. lymphedema.
Which of the following conditions involves the bones of the joint? a. osteoarthritis b. bursitis c. effusion d. gout
a. osteoarthritis
A female client visits the clinic and tells the nurse that she began menarche at the age of 16 years. The nurse should instruct the client that she is at a higher risk for a. osteoporosis. b. osteomyelitis. c. lordosis. d. rheumatoid arthritis.
a. osteoporosis.
A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment? a. place a small pillow under the client's knees b. remove a pillow from behind the client's head c. raise the head of the bed to a 30-degree angle d. assist to a sitting position with the legs dangling
a. place a small pillow under the client's knees
Skeletal muscles are attached to bones by a. tendons. b. fibrous connective tissue. c. cartilage. d. ligaments.
a. tendons.
Which of the following is an expected finding when palpating the abdomen? a. voluntary guarding b. superficial masses c. rigidity d. tenderness
a. voluntary guarding (intentional tensing of muscles)
You are teaching a client about recommendations to prevent colorectal cancer. Which of the following should be included in the teaching? (select all that apply) a. consume a diet that is high in fats and simple carbohydrates b. engage in moderate exercise for 30 minutes per day c. achieve and maintain a weight within the recommended BMI d. limit alcohol intake to 4 to 5 drinks per day e. take a probiotic daily
b and c
Which of the following characteristics should be noted when assessing the presence of a murmur? Select all that apply. a. Amplitude b. Location c. Loudness d. Pattern e. Pitch f. Quality
b, c, d, e, and f
The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply. a. Age b. Smoking c. Family history d. Cholesterol e. Blood pressure
b, d, and e
A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regard to this finding? a. "Do you have high blood pressure?" b. "Have you been pregnant?" c. "Have you noticed any color change to the skin?" d. "Are you experiencing any abdominal pain?"
b. "Have you been pregnant?"
The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease? a. "Try to ensure that you're screened for heart disease at least once every six months." b. "Your risk for heart disease will drop greatly if you're able to stop smoking." c. "If you can eliminate red meat from your diet, your risk of heart disease will drop significantly." d. "Anything that you can do to reduce stress in your life will benefit your heart health."
b. "Your risk for heart disease will drop greatly if you're able to stop smoking."
When assessing muscle tone and strength, the nurse would document expected findings as a. "upper and lower extremity muscle strength is 5/5" b. "upper and lower extremity muscle strength is 5/5 bilaterally" c. "upper extremity muscle strength is 5/5 bilaterally" d. "extremity muscle strength is 5/5 bilaterally"
b. "upper and lower extremity muscle strength is 5/5 bilaterally"
When assessing the amplitude (force) of a peripheral pulse site, which of the following grading would be considered 'normal'? a. +1 b. +2 c. +3 d. +4
b. +2
A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? a. Native American b. Caucasian c. African American d. South Asian
b. Caucasian
What do the oscillations in the internal jugular veins reflect? a. Changing pressures within the right ventricle b. Changing pressures within the right atrium c. Changing pressures within the left ventricle d. Changing pressures within the left atrium
b. Changing pressures within the right atrium
A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action? a. Flush all ports with heparin solution. b. Check the insertion site for redness. c. Culture the tip of the central line. d. Discontinue the central line.
b. Check the insertion site for redness.
A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what? a. Tactile emphysema b. Crepitus c. Popping and cracking noises d. Grating noise
b. Crepitus
A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. What should the nurse do next? a. Recheck in 5 minutes after elevating the arm. b. Document this finding as normal. c. Refer the client for medical follow-up. d. Reassess after applying warm compresses.
b. Document this finding as normal.
During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing? a. Crepitus uteri flexion b. Effusion in the knee joint c. Osteoarthritis d. Ligament trauma
b. Effusion in the knee joint
Hearing a bruit when auscultating one of the abdominal arteries is considered a normal assessment finding for the abdomen. a. True b. False
b. False
A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test? a. Feel for a pulsation to the fingers in the lower hand b. Firmly compress the lower portion of the varicose vein c. Place the second hand 3 to 4 inches above the first hand d. Ask the client to sit on a chair for the examination
b. Firmly compress the lower portion of the varicose vein
When assessing a client for possible varicose veins, which of the following would the nurse do? a. Tell the client to raise his or her leg b. Have the client stand for the exam c. Dorsiflex the client's foot d. Obtain the ankle-brachial index
b. Have the client stand for the exam
When the client performs straight leg flexion, the client complains of pain that radiates down his leg. The nurse understands that this may indicate what? a. Arthritis b. Herniated disc c. Hip fracture d. Degenerative joint disease
b. Herniated disc
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what? a. Lordosis b. Kyphosis c. Ankylosing spondylitis d. Scoliosis
b. Kyphosis
A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? a. Ensure that the client's legs are over the side of the bed b. Legs should be elevated for 15 seconds c. Have the client stand upright after tourniquet removal d. Tourniquet should be put on before leg elevation
b. Legs should be elevated for 15 seconds
A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following? a. Internal abdominal oblique b. Linea alba c. Peritoneum d. Transverse abdominis
b. Linea alba
A nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known as which of the following? a. Endocardium b. Myocardium c. Pericardium d. Epicardium
b. Myocardium
What would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? a. Hard, painless Bouchard nodes b. Numbness c. No tingling d. Atrophy of the thenar prominence
b. Numbness
A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? a. Tachypnea b. Orthopnea c. Sleep apnea d. Pneumonia
b. Orthopnea
A nurse palpates a weak left radial artery on a client. What should the nurse do next? a. Document the finding in the client's record. b. Palpate both radial arteries for symmetry. c. Assess the left hand for pallor and coolness. d. Palpate the left ulnar artery.
b. Palpate both radial arteries for symmetry.
A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next? a. Auscultate the apical pulse. b. Palpate the brachial pulse. c. Document the finding. d. Refer the client for medical follow-up.
b. Palpate the brachial pulse.
What finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome? a. Stiffness in the hands and fingers after holding and releasing a tight fist b. Reports of tingling, numbness, and pain in the involved wrist c. A change in the color of the fingers from red to white (pale) d. Inability to perform active range of motion with the involved wrist
b. Reports of tingling, numbness, and pain in the involved wrist
The nurse auscultates the pulmonic value area in which region a. Second right intercostal space b. Second left intercostal space c. Left lower sternal border d. Fifth intercostal space, left midclavicular line
b. Second left intercostal space
The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation. a. Arms swinging in opposition b. Shuffling of feet c. Stands on heels and toes d. Weight evenly distributed
b. Shuffling of feet
Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus? a. Refer the client to an oncologist. b. Stop palpating and get medical assistance. c. Provide a dietician consult for the client. d. Counsel the client regarding hernia repair.
b. Stop palpating and get medical assistance.
A 52-year-old secretary comes to the office complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about 1 year. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married with four children. She denies alcohol, tobacco, or drug use. Pelvic examination reveals some atrophic vaginal tissue but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have? a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence
b. Stress incontinence
The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound? a. Blood is returning from the client's toe more slowly than normal. b. The client's toe is receiving an inadequate supply of blood. c. There is a disruption in osmotic pressure in the client's extremities. d. There is a blockage or infection in the client's lymphatic system.
b. The client's toe is receiving an inadequate supply of blood.
Which of the following findings are expected when auscultating the abdomen? a. silent abdomen b. borborygmi c. vascular sounds d. bowel sounds heard every 1 to 3 minutes
b. borborygmi (audible hyperactive bowel sounds)
Which of the following conditions is associated with jugular venous distention? a. severe dehydration b. heart failure c. peripheral artery disease d. heart murmur
b. heart failure
Which of the following is a finding of scoliosis? a. lateral deviation of the head in relation to the spine b. lateral curvature of the spine c. exaggerated curvature of the thoracic spine d. exaggerated curvature of the lumbar spine
b. lateral curvature of the spine
Which of the following findings from a musculoskeletal assessment should be reported to the provider? a. hollows present on either side of the olecranon process b. misalignment of the bones of the elbow c. rating of 5 on the muscle strength scale when evaluating the shoulder d. absence of ulnar deviation of the fingers
b. misalignment of the bones of the elbow
Which of the following abdominal organs releases insulin to regulate blood sugar? a. stomach b. pancreas c. gallbladder d. appendix
b. pancreas
The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible a. aortic aneurysm. b. paralytic ileus. c. fluid and electrolyte imbalances. d. gastroenteritis.
b. paralytic ileus
A nurse is assessing a client who reports pins and needles sensations to their right hand. Which of the following terms should the nurse use to describe the sensations? a. proprioception b. paresthesia c. dysesthesia d. sprain
b. paresthesia
During an assessment, the client describes vomiting moderate amounts that "smell like poop." The nurse might suspect a. hypercalcemia b. small bowel obstruction c. irritable bowel syndrome d. gastric varices
b. small bowel obstruction
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound? a. boryborgymi b. splenic rub c. normal bowel sounds d. vascular noise
b. splenic rub
Which of the following is an extra or unexpected heart sound? (select all that apply) a. S1 b. S2 c. S3 d. S4 e. murmur
c, d, and e
A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining if this client is truly experiencing an alteration in bowel pattern? a. "Have you changed your food intake this week?" b. "What is the consistency of your stools??" c. "How many times a day are you having a bowel movement?" d. "Do you have a bowel movement every day?"
c. "How many times a day are you having a bowel movement?"
Which of the following documentation provides the most accurate information to include in the medical record? a. +4 pitting edema b. edema present in the leg c. +4 pitting edema in the left lower leg d. the client appears to have edema in the leg due to heart failure
c. +4 pitting edema in the left lower leg
Where is Erb's point located? a. 3rd right rib space b. 4th right rib space c. 3rd left rib space d. 4th left rib space
c. 3rd left rib space
At what age should a client who is considered to have an average risk for colorectal cancer begin screenings? a. 30 years old b. 40 years old c. 50 years old d. 60 years old
c. 50 years old
Which of the following wounds is most likely attributable to neuropathy? a. A wound on a client's highly edematous ankle that is surrounded by pigmented skin b. A moderately painful wound on the lateral aspect of the client's ankle c. A painless wound on the sole of the client's foot, which is surrounded by calloused skin d. A painful wound in the client's shin, which is surrounded by apparently healthy skin
c. A painless wound on the sole of the client's foot, which is surrounded by calloused skin
When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2? a. Wide split b. Normal split c. Accentuated d. Diminished
c. Accentuated
A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis? a. Assist in active range-of-motion exercise of the upper body. b. Massage lower extremities vigorously every 6 hours. c. Assist the client to walk as soon and as often as possible. d. Raise the foot of the bed for an hour and then lower it.
c. Assist the client to walk as soon and as often as possible.
The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate? a. At the top of the foot b. Just behind the knee c. Behind the ankle d. In the groin area
c. Behind the ankle
Which of the following assessment findings is most congruent with chronic arterial insufficiency? a. Thickened and scarred skin on the client's ankle b. Ulceration on the medial surface of the client's ankle c. Cool foot temperature and ulceration on the client's great toe d. Brown pigmentation around a client's ankles and shins
c. Cool foot temperature and ulceration on the client's great toe
During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse? a. Popliteal b. Temporal c. Femoral d. Brachial
c. Femoral
A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause? a. Escherichia coli b. Staphylococcus aureus c. Helicobacter pylori d. Streptococcus pyogenes
c. Helicobacter pylori
You are able to assess the abdomen of a patient who has been experiencing diarrhea for the past two days. Which of the following assessment findings would you expect for this patient? a. Absent bowel sounds b. Hypoactive bowel sounds c. Hyperactive bowel sounds d. Normal bowel sounds
c. Hyperactive bowel sounds
The nurse is assessing a client's heart and neck vessels. Which technique would be mostappropriate to use when examining the client's jugular venous pulse? a. Have the client look straight ahead with chin slightly lifted. b. Perform the exam with the client in a supine position. c. Inspect the suprasternal notch or around the clavicles. d. Have the client sit up at a 90-degree angle.
c. Inspect the suprasternal notch or around the clavicles.
A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process? a. Peritonitis from a ruptured diverticulum b. Acute onset of appendicitis with possible rupture c. Internal adhesions from previous surgery d. Intestinal obstruction at the sigmoid colon
c. Internal adhesions from previous surgery
The nurse is preparing to assess a client's carotid arteries. Which nursing action would be mostappropriate? a. Ask the client to breathe in and out deeply. b. Palpate the arteries before auscultating them. c. Palpate each artery individually to compare. d. Use the diaphragm of the stethoscope.
c. Palpate each artery individually to compare.
The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this client? a. Ballottement b. Tinel's c. Phalen's d. McMurray's
c. Phalen's
Where does the electrical conduction/electrical firing within the heart begin? a. AV node b. Bundle branches c. SA node d. Purkinje fibers
c. SA node
The stethoscope bell should be pressed lightly against the skin so that: a. Chest hair does not stimulate crackles b. High- pitched sounds can be heard better c. The bell does not act as a diaphragm d. The bell does not interfere with amplification of heart sounds
c. The bell does not act as a diaphragm
Which of the following is true when auscultating the abdomen for bowel sounds. a. Bowels sounds should be heard every 1 to 2 seconds. b. Bowels sounds are absent if not heard within 1 minute. c. The nurse should auscultate the abdomen for bowel sounds in all 4 quadrants for 2 minute. d. The nurse should auscultate the abdomen for bowel sound by using the bell of the stethoscope
c. The nurse should auscultate the abdomen for bowel sounds in all 4 quadrants for 2 minute.
While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. What would the nurse include? a. circumduction b. abduction c. flexion d. internal rotation
c. flexion
Which of the following actions should the client take when applying cold therapy after a sprain? a. apply a cold pack directly onto the skin b. discontinue use of the cold pack 12 hours following the surgery c. limit the use of the cold pack to 20 minutes at a time d. the use of the cold pack will help with repair of the ligaments
c. limit the use of the cold pack to 20 minutes at a time
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should a. ask the client to assume a side-lying position. b. palpate lightly while slowly releasing pressure. c. palpate deeply while quickly releasing pressure. d. perform this abdominal assessment first.
c. palpate deeply while quickly releasing pressure.
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? a. left lower b. left upper c. right upper d. right lower
c. right upper
The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing a. lordosis. b. arthritis. c. scoliosis. d. kyphosis.
c. scoliosis.
Which of the following is a ball and socket joint? a. elbow b. knee c. shoulder d. wrist
c. shoulder
Chronic arterial occlusion, usually from atherosclerosis, causes intermittent __________.
claudication
A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply. a. Circumduction b. Rotation c. Abduction d. Supination e. Extension f. Flexion
d, e, and f
Which of the following would be an appropriate question to collect subjective data about the client's past health history? a. "Do you have any family members with liver disease?" b. "Do you have any painful or tender areas?" c. "Have you noticed changes in your appetite or weight gain or loss?" d. "Have you had any previous abdominal surgeries?"
d. "Have you had any previous abdominal surgeries?"
What is an appropriate question by the nurse to ask a client about the presence of temporomandibular joint dysfunction? a. "Do you notice any swelling around the teeth or gums?" b. "Please stick out your tongue sand move it from side to side" c. "Can you fully clench your teeth and feel the muscles in your jaw tense?" d. "Have you noticed a popping or grating sound when you chew?"
d. "Have you noticed a popping or grating sound when you chew?"
Which of the following client reports indicates a medical emergency? a. "I have been wheezing when I'm around flowers" b. "I forgot to take my water pill this morning" c. "I have a family history of heart disease" d. "I have a tight feeling in my chest"
d. "I have a tight feeling in my chest"
Which of the following ratings should you assign a bounding carotid pulse? a. +1 b. +2 c. +3 d. +4
d. +4
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? a. Murmurs b. Normal findings c. Gallops d. Bruits
d. Bruits
Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client? a. Significance of cardiac dysrhythmias b. Prevention of varicose veins c. Exercise tolerance d. Extent of tobacco use and exposure
d. Extent of tobacco use and exposure
Which of the following people need to be vaccinated for hepatitis A and B? a. Office personnel b. Truck drivers c. Animal care workers d. Food-service workers
d. Food-service workers
What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen? a. Inogastric b. Epigastric c. Hypochondriac d. Hypogastric
d. Hypogastric
A school age client has been diagnosed with genu valgum. What is the other name for this disease? a. Flatfeet b. Bowlegs c. Clubfoot d. Knock kneed
d. Knock kneed
A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor? a. Small-boned, thin frame b. Personal history of fractures c. Age d. Low estrogen levels
d. Low estrogen levels
The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location? a. Left lower quadrant b. Left upper quadrant c. Right upper quadrant d. Right lower quadrant
d. Right lower quadrant
The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process? a. Cool temperature b. Nodules c. Ecchymosis d. Tenderness
d. Tenderness
After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following? a. Chordae tendineae b. Semilunar valves c. Precordium d. Ventricles
d. Ventricles
The bicuspid, or mitral, valve is located a. at the beginning of the ascending aorta. b. at the exit of each ventricle near the great vessels. c. between the right atrium and the right ventricle. d. between the left atrium and the left ventricle.
d. between the left atrium and the left ventricle.
Joints may be classified as cartilaginous, synovial, or a. flexible. b. immobile. c. articulate. d. fibrous.
d. fibrous.
The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of a. patent ductus arteriosus. b. pulmonary emphysema. c. diastolic murmurs. d. increased central venous pressure.
d. increased central venous pressure.
A client is unable to externally rotate the left shoulder. What health problem should the nurse suspect is occurring with this client? a. anterior dislocation of the humerus b. rotator cuff tendinitis c. carpal tunnel syndrome d. rotator cuff tear
d. rotator cuff tear
The subacromial bursae are contained in the a. wrist joint. b. temporomandibular joint. c. elbow joint. d. shoulder joint.
d. shoulder joint.
In __________, left ventricular pressure continues to drop and falls below left atrial pressure.
diastole
Coffee-grounds emesis or emesis with red blood is referred to as __________.
hematemesis
The innermost layer of all blood vessels is the __________.
intima
Stress incontinence arises from decreased __________ pressure.
intraurethral
The __________ joint is the largest joint in the body.
knee
The __________ is the heart muscle that does the pumping.
myocardium
The heart lies in the __________ cavity in the mediastinum under the sternum and between the 2nd and 5th intercostal spaces.
pericardial
Visceral __________ pain may signify early acute appendicitis from distention of an inflamed appendix.
periumbilical
Nonpitting edema reflects a condition in which serum __________ have accumulated in the interstitial space with the water and coagulated.
proteins
In infants, the bladder empties by reflex mechanisms in the _________ spinal cord.
sacral
The aortic and pulmonic valves are called __________ valves because each of their leaflets is shaped like a half moon.
semilunar
Scoliosis may cause elevation of one _________.
shoulder
The __________ joint is the most active joint in the body.
temporam ibular
The wrist includes the distal radius and __________ and eight small carpal bones.
ulna
