366 Test 3 Prep u

A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ? Kidney Liver Spleen Gallbladder

kidney

x The area known as Erb's point is the third site for auscultation on the precordium. Where is it located? 4th left rib space 3rd right rib space 4th right rib space 3rd left rib space

3rd left rib space

When assessing a client's strength, it is necessary to Compare one side to the other Assess the extremities at the same time Compare upper and lower extremities Assess upper and lower extremities at the same time

Compare one side to the other

A nurse is demonstrating the technique for auscultating heart sounds. Which of the following would be most important for the nurse to emphasize? Start at the apex. Listen over each of the heart chambers. Use both the bell and diaphragm. Cover the entire precordium.

Cover the entire precordium.

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? Crepitus Grating noise Tactile emphysema Popping and cracking noises

Crepitus

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? Circumduction Flexion Abduction Internal rotation

Flexion

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved? Gallbladder Kidneys Stomach Pancreas

Gallbladder

A nurse inspects a child's legs with the child standing and notices that the knees turn inward. How should this finding be documented in the medical record? Genu varum Genu valgum Bowed legs Ballottement

Genu valgum

When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as? Summation gallop Atrial kick Ejection clicks Diastolic clicks

summation gallop

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? 2/5 3/5 4/5 5/5

4/5

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate? "I'm going to examine the area where you're having pain first to get a better picture of what's going on." "Before I get ready to examine the painful area, I will let you know in plenty of time." "You don't need to worry about anything. I will make sure to be very gentle during the exam." "Since you're having pain in a certain area, I won't have to do a very thorough exam there."

"Before I get ready to examine the painful area, I will let you know in plenty of time."

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? "What is the consistency of your stools??" "How many times a day are you having a bowel movement?" "Do you have a bowel movement every day?" "Have you changed your food intake this week?"

"How many times a day are you having a bowel movement?"

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating? 4 3 2 1

1

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. How would the nurse document this finding in the client's electronic medical record? 1+ 2+ 3+ 4+

2+

The nurse is percussing a client's liver and is assessing liver descent. The nurse would have the client do which of the following? Cough forcefully Hold his or her breath Breathe deeply Perform the Valsalva maneuver

Breathe deeply

x Moving a part of the body away from the midline is called? Abduction Adduction Rotation Extension

Abduction

Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause? An enlarged liver felt during palpation Report of a decrease in appetite Tympany percussed over the stomach Negative fluid wave test

An enlarged liver felt during palpation

An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What might this client's medical diagnosis be? Gastroenteritis Liver disease Appendicitis Enlarged spleen

Appendicitis

A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test? Ask the client to raise the leg to the point of pain and then dorsiflex the foot Instruct the client to bend forward and touch the toes Instruct the client to touch the chin to the chest Palpate the spinous processes and the paravertebral muscles

Ask the client to raise the leg to the point of pain and then dorsiflex the foot

A client's bladder is found to be distended. At which location would the nurse begin palpating? At the umbilicus At the symphysis pubis In the right lower quadrant In the left lower quadrant

At the symphysis pubis

Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect? Ascites Appendicitis Cholecystitis Splenomegaly

Cholecystitis

The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by Congestive heart failure and pyelonephritis Cirrhosis and nephrosis Metastatic neoplasms and coronary artery disease Congestive heart failure and coronary artery disease

Cirrhosis and nephrosis

The nurse is examining an older adult client. During the physical assessment, the client appears to be getting fatigued. What can the nurse do to help the client finish the assessment? Divide the assessment into portions Rush through each activity to finish more quickly Omit tests Halt the assessment, and finish when the client has enough strength

Divide the assessment into portions

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what? Adducting and abducting Dorsiflexion and plantar flexion Supination and pronation Rotation and supination

Dorsiflexion and plantar flexion

The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location? Second intercostal space, left sternal border Third intercostal space, left axillary line Fourth intercostal space, left sternal border Fifth intercostal space, left midclavicular line

Fifth intercostal space, left midclavicular line

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen? Flex the client's legs by placing a pillow under the knees Raise the client's arms or fold them behind the head Avoid the use of pillow under the head during examination Provide privacy to the client and instruct him to relax

Flex the client's legs by placing a pillow under the knees

Which movement should the nurse instruct the client to perform to assess range of motion for the knee? Flexion Circumduction Rotation Abduction

Flexion

A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process? Rheumatoid arthritis Verruca vulgaris (warts) Degenerative joint disease Gouty arthritis

Gouty arthritis

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. What would the nurse suspect? Gouty arthritis Rheumatoid arthritis Degenerative joint disease Plantar fasciitis

Gouty arthritis

The nurse is assessing an adult client with right lower quadrant abdominal pain. The client has no history of prior surgeries, has no allergies, and is physically fit. Which of the following should the nurse do during the abdominal examination? Observe the client's face for signs of discomfort Examine the abdomen with the client's bladder full Place the client supine with arms extended up Do not distract the client with questions while performing the examination

Observe the client's face for signs of discomfort

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade? I II III IV

II

Which finding in an elderly client requires additional assessment by a nurse when inspecting the musculoskeletal system? Symmetrical atrophy of the biceps muscles Inability to button the jacket due to swollen finger joints Slow and steady gait with a wide base of support An exaggerated thoracic curve (kyphosis)

Inability to button the jacket due to swollen finger joints

Which technique would be most appropriate to use when examining the jugular venous pulse? Perform the exam with the client in a supine position. Have the client look straight ahead with chin slightly lifted. Have the client sit up at a 90-degree angle. Inspect the suprasternal notch or around the clavicles.

Inspect the suprasternal notch or around the clavicles.

x A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? Palpate, percuss, inspect, auscultate Auscultate, inspect, palpate, percuss Inspect, auscultate, percuss, palpate Percuss, inspect, auscultate, palpate

Inspect, auscultate, percuss, palpate

When performing the abdominal assessment for a client, which assessment technique should the nurse perform first? Auscultation Inspection Percussion Palpation

Inspection

A nurse determines that the liver span of an older adult male client measures 6 cm. How would the nurse would interpret this finding? It is a normal-sized liver. The liver is larger than normal. The liver is smaller than normal. The liver has atrophied.

It is a normal-sized liver.

A nurse auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one minute. What is an appropriate action by the nurse? Document the absence of bowel sounds Assess for findings of dehydration Listen for a total of five (5) minutes Palpate for abdominal rigidity

Listen for a total of five (5) minutes

Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what? Lordosis Kyphosis Scoliosis Keracytosis

Lordosis

A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee? Ballottement McMurray's Bulge Phalen's

McMurray's

A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test? Obturator Murphy's Psoas Rovsing's

Murphys

After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data? Denies pain in hips or legs Complains of burning in lower back Neck rotation limited to 50 degrees History of osteoporosis

Neck rotation limited to 50 degrees

What would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? Numbness Atrophy of the thenar prominence No tingling Hard, painless Bouchard nodes

Numbness

Loss of bone density that occurs with greatest frequency in postmenopausal women is called? Osteoporosis Scoliosis Kyphosis Lordosis

Osteoporosis

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? Bundle of His Purkinje fibers Pacemaker Conduction system

Pacemaker

The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate? Palpate each artery individually to compare Palpate the arteries before auscultating them Use the diaphragm of the stethoscope Ask the client to breathe in and out deeply

Palpate each artery individually to compare

client has been admitted to the cardiac unit and test results are available. The nurse is writing a plan of care for this client. On what would the nurse base interventions? Patterns of subjective and objective data Patterns of test results Areas for care planning Areas that the client requests

Patterns of subjective and objective data

Which action by a nurse is a correct method for performing the Tinel's test to determine the presence of carpel tunnel syndrome? Percuss lightly on the inner aspect of the wrist. Palpate the hollow area on the back of the wrist. Ask the client to bend the wrist down and back. Perform wrist movements against resistance.

Percuss lightly on the inner aspect of the wrist.

While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following? Pericardial friction rub Midsystolic click Summation gallop Aortic ejection click

Pericardial friction rub

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? S1 S2 Preload Afterload

S2

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole? S1 S2 S3 S4

SI

The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation. Weight evenly distributed Shuffling of feet Stands on heels and toes Arms swinging in opposition

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? Refer the client to an oncologist. Provide a dietician consult for the client. Counsel the client regarding hernia repair. Stop palpating and get medical assistance.

Stop palpating and get medical assistance.

After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which location as Erb's point? Fifth intercostal space near the left midclavicular line Third intercostal space at the left sternal border Second intercostal space at the right sternal border Second or third intercostal space at the left sternal border

Third intercostal space at the left sternal border

The nurse is admitting a new client to the floor and asks if the client has any dizziness. Why does the nurse do this? To assess for liver problems To assess for pancreatic problems To check for possible dehydration To check for an absorption problem

To check for possible dehydration

A student is performing a physical assessment on a client. While assessing the abdomen, the student percusses the spleen. What sound would be normal for the student to hear? Tympany Dullness Hollow sound Friction rub

Tympany

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? Abdominal respiratory movements Visible peristaltic waves Symmetric appearance No bulging with head raising

Visible peristaltic waves

The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve? III V VII XI

XI

x The nursing instructor is discussing assessment of the heart with students. A student states that he has a client with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling? A thrill A thrust A heave A normal finding

a thrill

Which of the following acute abdominal symptoms could be life threatening? Abdominal pain Striae Kidney stones Indigestion

abdominal pain

A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen? Absent Hyperactive Hypoactive Erratic

absent

Which joint movement is a nurse testing when asking a client to move an extremity towards the body? Flexion Extension Adduction Abduction

adduction

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? Angina Musculoskeletal Gastrointestinal Crushing

angina

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves? Aortic and pulmonic Tricuspid and mitral Pulmonic and tricuspid Mitral and aortic

aortic and pulmonic

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? Listen with the bell for the high pitched sounds of normal S1S2 Elevate the head of bed until the examiner can comfortably reach the client Auscultate to determine the heart rate and if the rhythm is normal Stand at the client's left side and perform the entire assessment from this position

auscultate to determine the heart rate and if the rhythm is normal

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. What test would the nurse perform to confirm the suspicion? Phalen's test Tinel's test Ballottement test Lasegue's test

ballottement test

A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse? Normal Tachycardia Bradycardia Decreased

bradycardia

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? Bruits Murmurs Normal findings Gallops

bruits

To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment? Carotid artery pulse Jugular venous pulse Apical impulse Heart sounds

jugular venous pulse

A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source? Cardiac Gastrointestinal Musculoskeletal Pulmonary

cardiac

Which of the following anterior neck structures is found in the depression between the trachea and the sternomastoid muscle? Internal jugular vein External jugular vein Trachea Carotid artery

carotid artery

The nurse positions the client for auscultation of heart sounds. What does the nurse do first? Clean the stethoscope Warm the bell of the stethoscope Wash the client's chest Auscultate the carotid arteries

clean the stethoscope

The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action? Isometric contraction Closure of the semilunar valves Beginning of diastole Closure of the atrioventricular valves

closing of the atrioventricular valves

A nurse understands that the cardiac event that cycles the beginning of systole is what? Closure of the mitral and tricuspid valves Closure of the aortic and pulmonic valves Relaxation of the ventricles Contraction of the ventricles

closure of the mitral and tricuspid valves

A nurse recognizes that the second heart sound, S2, is produced by which cardiac action? Isometric contraction Closure of the atrioventricular valves Closure of the semilunar valves Ventricular contraction

closure of the semilunar valves

During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate? Refer the client for medical follow-up. Evaluate further for a problem with the spleen. Assess urinary output. Document the position of the liver.

document the position of the liver

A new client is admitted to a long term care facility. The nurse assesses the client with an unsteady gait and incontinence. Which problem should the nurse address when planning care for this client? Falls Osteoporosis Low back pain Neck pain

falls

After teaching a group of students about the great vessels, the instructor determines that the students need additional teaching when they identify which of the following as a great vessel? Aorta Pulmonary vein Femoral artery Inferior vena cava

femoral artery

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what? Flat neck veins Round neck veins Distended neck veins Invisible neck veins

flat neck veins

Which of the following tools would a nurse practitioner be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a client? Flashlight Gradiometer Scale Goniometer

goniometer

The nurse hears a quiet murmur immediately after placing the stethoscope on the chest. Documentation of grading for this murmur would include grade 2 grade 1 grade 3 grade 4

grade 2

A nurse auscultates a murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur? Grade I/VI Grade VI/VI Grade II/VI Grade V/VI

grade v/vi

A group of students is reviewing information about the different types of murmurs. Which of the following would they identify as examples of midsystolic murmurs? Innocent Mitral regurgitation Mitral stenosis Ventricular septal defect

innocent

x Across the lifespan, a nurse knows that the female heart Is normally smaller than the male heart Weighs more than a male heart Is normally larger than a male heart Normally beats slower than a male heart

is normally smaller than the male heart

A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position? Supine with head of bed elevated 30 degrees Leaning forward while in a sitting position Flat, left lateral Sitting upright in a straight back chair

leaning forward while in a sitting position

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? left midclavicular line at the third intercostal space right of the midclavicular line at the third intercostal space left midclavicular line at the fifth intercostal space right of midclavicular line at the fifth intercostal space

left midclavicular line at the fifth intercostal space

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? Small-boned, thin frame Personal history of fractures Low estrogen levels Age

low estrogen levels

A nurse performs inspection and palpation of a client's knee and detects swelling. What is the appropriate test the nurse should perform next to determine the location of the swelling? Ballotment McMurray's Range of motion Bulge

mcmurry's

A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system? Apical heart rate 70 beats per minute No current medications or treatments No edema of extremities noted Apical impulse palpated at 5 intercostal space on left

no current medications or treatment

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? Orthopnea Tachypnea Pneumonia Sleep apnea

orthopnea

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should know that this would be documented as what type of sound? Paradoxical sound Split sound Pericardial murmur Pericardial friction rub

pericardial friction rub

When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following? Hallus valgus Pes varus Verruca vulgaris Pes cavus

pes varus

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 patient? Phalen's Tinel's Ballottement McMurray's

phalen's

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following? Pronation Flexion Rotation Supination

pronation

What is the most important lifestyle changes a client can make to improve cardiovascular health? Quitting smoking Eating a diet high in fat Living a more sedentary lifestyle Getting less exercise and more rest

quitting smoking

When evaluating the jugular venous pressure in a patient with known coronary artery disease, the nurse explains to the patient that the JVP measures the pressure in the right atrium left atrium right ventricle left ventricle

right atrium

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse charts "Swooshing sound heard over right carotid artery." How should this documentation be corrected? "Murmur heard over right carotid artery" "Split sound auscultated over right carotid artery" "Right carotid bruit auscultated" Does not need to be corrected

right carotid bruit auscultated

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? Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant

right lower quadrant

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? Gallbladder Liver Spleen Head of pancreas

spleen

In order for the nurse to assess jugular venous pressure (JVP), the client should be in which of the following positions? The head of the bed raised 30 degrees The head of the bed raised 60 degrees The head of the bed raised 90 degrees The client lying supine

the head of the bed raised 60 degrees

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? Chordae tendineae Ventricles Semilunar valves Precordium

ventricles