Coursepoint Exam 2 Questions

The nurse is caring for an adult female client when the client tells the nurse that she has had a clear discharge from her nipples for the past month. The nurse should ask the client if she has been taking

contraceptives

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?

forward protrusion

The functional part of the breast that allows for milk production consists of tissue termed

glandular

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students needs further instructions when the student says that one risk factor is

having a baby before the age of 20 years

The lymph nodes that are responsible for drainage from the arms are the

lateral lymph nodes

Which of the following assessment findings is most likely benign on breast examination?

one breast larger than the other

A mother brings her adolescent son into the clinic because she is concerned about his development of breast tissue. Her son denies use of any medications and is slender in appearance. What should be the nurse's next action?

palpate for any irregular or hard masses

What instruction should the nurse provide to a client to assess for dimpling or retraction of breast tissue?

raise arms over the head

During the physical examination of a client's breast, which finding should the nurse recognize as a possible indication of a malignant tumor?

retraction of nipples

When inspecting the nipples, which of the following findings is unexpected?

retraction of the left nipple

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse?

"Do you feel anxious at times?"

A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?

"Hormones affect the severity of migraine headaches."

The nurse is assessing a client's progress in smoking cessation according to the Stages of Change Model. Which statement indicates that the client is in the Action stage?

"I just quit smoking today"

The client is experiencing severe sepsis. What assessment finding would the nurse expect?

1+ pulses

The nurse notes that a client has decreased fremitus in the left upper lung lobe. What should the nurse consider as causing this assessment finding? Select all that apply. 1. Pleural effusion 2. Asthma 3. Bronchial obstruction 4. Pneumonia 5. Pneumothorax

1. penumothorax 2. pleural effusion 3. bronchial obstruction

A client denies performing breast self-examination however practices breast awareness. What is this client focusing on when following this practice?

Appearance, feel, and shape of the breasts and nipples

A nurse is inspecting a client's breasts. The nurse notices that one breast is larger than the other. Which action should the nurse take next?

Ask the client whether the larger breast has increased in size recently

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess the client regarding characteristics of the pain.

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7

What is the most common type of hyperthyroidism?

Graves' disease

A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse?

Notify the health care provider

A nonpregnant female presents to the health care facility and reports new onset of breast discharge. The nurse assesses the discharge to be milky in appearance without breast tenderness or masses. What additional data should the nurse obtain from this client?

Prescribed medications such as antipsychotic agents

The submandibular glands open under the tongue through openings called

Wharton ducts

The nurse is preparing to examine the breasts of a female client who had a left radical mastectomy 3 years ago. When examining the client, the nurse observes redness at the scar area. The nurse should explain to the client that this may be indicative of?

an infectious process

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

anteroposterior to lateral

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

atelectasis

A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue?

both sides

A nurse is interviewing a client who complains of dyspnea. Which of the following findings would tend to indicate an underlying cardiovascular problem in the client? Select all that apply. 1. coughing that produces white sputum 2. angina 3. coughing occurring at night 4. orthopnea 5. edema 6. snoring and gasping while sleeping

1. edema 2. angina 3. orthopnea

A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

impaired gas exchange

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

inspect the nostrils with an otoscope

The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?

pleural effusion

The nurse is assessing a client who appears to have a swollen thyroid gland (goiter). Which of the following is a priority question the nurse should ask the client?

"Do you have any difficulty swallowing?"

A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record?

4+

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?

arthritic changes of the cervical spine

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where:

cancers often occur

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

dermis

Under normal circumstances, the strongest stimulus to breathe is

hypercapnia

The clavicles extend from the acromion of the scapula to the part of the sternum termed the?

manubrium

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?

palmar base

The anterior chest area that overlies the heart and great vessels is called the

precordium

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

receding and ischemic gums

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension

A mother brings her 5-year-old son who is of African descent to the clinic. The mother is concerned about recent changes in her child's hair color from black to a copper-red. What is the best response by the nurse?

"this could be a sign of malnutrition"

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

3

A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?

A grey-white line

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?

A large amount of exudate in the sinuses

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?

Graves' disease

A 44-year-old woman comes to the clinic complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-breast examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. Examination shows a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath a nontender 2-cm mass is palpable. The axilla contains only soft moveable nodes. The left breast examination and axilla are unremarkable. What visible skin change of the breast does she have?

Paget's disease

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis

Benign conditions of the breast include

fibrocystic changes

When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck?

limitations in movement

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially?

malignant melanoma

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

psoriasis, fungal infections, trauma

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:

reduction of the bloody supply to the brain

While conducting a comprehensive assessment on a new client, the client states, "I've had these mouth and tongue sores for a few weeks that do not seem to heal." The nurse assesses the client's mouth and finds thickened lumpy areas with a rough and crusty appearance. What is the best action of the nurse?

refer the client for further evaluation fo the sores

Connecting the skin to underlying structures is/are the?

subcutaneous tissue

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

the client has chronic hypoxia

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?

thrush

The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse?

"Loss of sensation in the toes is an age-related change."

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the bestresponse by the nurse?

"it takes about 6 months to totally replace a fingernail"

Which of the following clients is most likely to be diagnosed with migraine headaches?

A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

When performing a breast assessment on a clinic client, the nurse practitioner notes scaly lesions that begin at the nipple and move toward a lump behind the nipple well. The NP would know that further assessment for what would be necessary?

Paget's disease

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

airway patent, breathing quite, denies dyspnea

Hair follicles, sebaceous glands, and sweat glands originate from the?

dermis

Which is true of a third heart sound (S3)?

it is caused by rapid deceleration of blood against the ventricular wall

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

observe for use of accessory muscles

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

unequal expansion of the chest

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration

Elevated sebaceous glands, known as Montgomery glands, are located in the breast's

areolas

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?

bacterial infection

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is mostlikely experiencing which of the following disorders?

cerebrovascular accident

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

chronic bronchitis

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates?

diabetic ketoacidosis

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

distribution

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

dullness

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

dysphagia

A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding?

goiter

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse would document this finding as being:

herpes simplex

You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?

hoarseness

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the

maxillary sinuses

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

notify the healthcare provider immediately

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

osteomyelitis

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

tines corporis

A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color?

melanin

Short, pale, and fine hair that is present over much of the body is termed

vellus

A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?

"The area of cramping is close to the area of arterial occlusion."

A nurse is examining the breasts of a 75-year-old woman. Which of the following are normal findings in the breasts of an older adult? Select all that apply.

1. smaller, flatter nipples 2. Nipples that are less erectile on stimulation 3. pendulous breasts

Which of the following veins drain into the superior vena cava? (Mark all that apply.) 1. Lower extremities 2. Upper extremities 3. Upper torso 4. Head 5. Lower torso

1. upper torso 2. head 3. upper extrememties

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply. 1. Ask the client to remove only his shirt 2. Have the client stand for the entire examination 3. Use sunlight, if possible, to inspect the skin 4. Have the client remove his toupee 5. Wear gloves when palpating lesions 6. Keep the room door closed

1. use sunlight, if possible, to inspect the skin 2. Have the client remove his toupee 3. Wear gloves when palpating lesions 4. Keep the room door closed

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?

Firmly compress the lower portion of the varicose vein

When learning about hereditary variability, the student would learn that what ethnic group has the highest number of premature deaths due to heart disease?

Native American

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition?

Place the bell of the stethoscope over the apex with client on left side.

The nurse is assessing the jugular venous pressure (JVP) of a 72-year-old client with recent complaints of fatigue, shortness of breath, and swollen ankles. What cardiac phenomena are represented by the oscillations that the nurse observes in the client's internal jugular veins?

The pressures that exist within the client's right atrium

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves?

Trendelenburg test

The radial pulse is palpated over the lateral flexor surface. (True or false?)

True

What is a long-term complication of peripheral vascular disease?

amputation

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

The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?

arterial occlusion

A client comes to the clinic reporting pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, and forehead for the past 12 weeks. Based on these findings, which of the following disorders is the client most likely experiencing?

chronic sinusitis

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the?

competence of the saphenous vein valves.

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

grade 5

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

hypovolemia

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what?

intermittent claudication

A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?

lower arm and hand for erythema and swelling

While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of?

mitral valve stenosis.

A 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

What is the most important physical sign of acute pericarditis?

pericardial friction rub

When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause?

peripheral arterial disease

What is a function of the lymph system?

produce antibodies

A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia?

sinus arrhythmia

The nurse notes that a client's heart rate speeds up with inspiration and slows down with expiration. What should the nurse suspect this client is demonstrating?

sinus arrhythmia

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

skin is warm and dry to the touch

When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as?

summation gallop

Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?

tongue fissures

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's?

vesicles

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:

vestibule, nasal passages, and nasopharynx

Which of the following would put the client at risk for falls? Select all that apply. 1. Diaphoresis 2. Palpitations 3. Hypotension 4. Confusion 5. Dizziness

1. dizziness 2. hypotension 3. confusion

An older adult client has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the nurse practitioner want to have this client assessed for by a cardiologist?

atherosclerosis stenotic carotid arteries

The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication?

lymphoma

A nurse palpates the breasts of a client for masses during the physical examination. The nurse knows that if a tumor if malignant, which characteristics will be present? Select all that apply. 1. rubbery and mobile 2. fixed to underlying tissues 3. irregular in shape 4. hard and nontender 5. well-demarcated borders

1. hard and nontender 2. fixed to underlying tissues 3. irregular in shape

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1. intact, firm skin with redness 2. full-thickness skin loss 3. ulceration involving the dermis 4. necrosis with damage to underlying muscle

1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle

A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse?

ask the client to assume the left lateral position

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

coarse crackles

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease?

diabetes

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

right cervical node

Symptoms of complete arterial occlusion include which of the following? Select all that apply. 1. Pain 2. Color change 3. Heat 4. Numbness 5. Erythema

1. numbness 2. color change 3. pain

A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.) 1. Press up on the area next to the ear. 2. Press down on the lower jaw. 3. Press up on the frontal sinuses from under the bony brows. 4. Press down on the head. 5. Press up on the maxillary sinuses.

1. press up on the frontal sinuses rom under the bony brows 2. Press up on the maxillary sinuses

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension

A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event?

The time from firing of the sinoatrial (SA)node to the beginning of depolarization in the ventricle

A nurse performs a comprehensive assessment on a new client. The nurse observes the following findings: bilateral lower extremities are cool to touch with sparse hair distribution, legs blanch when raised, and client reports leg pain when walking long distances that resolves with rest. The nurse determines these are signs and symptoms of which of the following disorders?

arterial insufficiency

A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding?

assess adequacy of blood flow using a Doppler device

The nurse is assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the client's pain be most concerning?

calf

A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency?

pallor of foot occurs with elevation

During an instruction session on breast self-examination, the nurse would instruct a client to perform the exam at which time?

right after the menstrual period ends