Exam 3 Practice Questions

The nurse is performing a nutritional assessment on a 15-year-old girl who tells the nurse that she is so fat. Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurses appropriate response would be: a. How much do you think you should weigh? b. Dont worry about it; youre not that overweight. c. The best thing for you would be to go on a diet. d. I used to always think I was fat when I was your age.

a. How much do you think you should weigh?

Which statement is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate a large blood volume increase.

b. The arterial system is a high-pressure system. The pumping heart makes the arterial system a high-pressure system.

During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms do a much better job than I ever could to find a lump. The nurse should explain to her that: a. BSEs may detect lumps that appear between mammograms. b. BSEs are unnecessary until the age of 50 years. c. She is correct mammography is a good replacement for BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually.

a. BSEs may detect lumps that appear between mammograms.

The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue. c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born.

c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. a. Ulnar b. Radial c. Brachial d. Deep palmar

c. Brachial The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct? a. BSE is more important than ever for you because you have never had any children. b. BSE is so important because one out of nine women will develop breast cancer in her lifetime. c. BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations. d. BSE will save your life because you are likely to find a cancerous lump between mammograms.

c. BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations.

The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in black women in the United States? a. Breast cancer is not a threat to black women. b. Black women have a lower incidence of regional or distant breast cancer than white women. c. Black women are more likely to die of breast cancer at any age. d. Breast cancer incidence in black women is higher than that of white women after age 45.

c. Black women are more likely to die of breast cancer at any age.

During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? a. Certain drugs can affect the metabolism of nutrients. b. The nurse needs to assess the patient for allergic reactions. c. Medications need to be documented in the record for the physicians review. d. Medications can affect ones memory and ability to identify food eaten in the last 24 hours.

a. Certain drugs can affect the metabolism of nutrients.

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patients abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least: a. 1 minute. b. 5 minutes. c. 10 minutes. d. 2 minutes in each quadrant.

b. 5 minutes.

The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult? a. Increase in taste and smell b. Living alone on a fixed income c. Change in cardiovascular status d. Increase in gastrointestinal motility and absorption

b. Living alone on a fixed income

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37 year old who is slightly overweight b. 42 year old who has had ovarian cancer c. 45 year old who has never been pregnant d. 65 year old whose mother had breast cancer

d. 65 year old whose mother had breast cancer

When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a. Height and weight. b. Leg circumference. c. Skinfold thickness of the biceps. d. Hip and waist measurements.

a. Height and weight.

The nurse recognizes which of these persons is at greatest risk for undernutrition? a. 5-month-old infant b. 50-year-old woman c. 20-year-old college student d. 30-year-old hospital administrator

a. 5-month-old infant

The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? a. Absorption of nutrients may be impaired. b. Constipation may represent a food allergy. c. The patient may need emergency surgery to correct the problem. d. Gastrointestinal problems will increase her caloric demand.

a. Absorption of nutrients may be impaired.

A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it was nothing to worry about. The examination validates the presence of a mass in the right upper outer quadrant at 1 oclock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. The nurse replies: a. Because of the change in consistency of the lump, it should be further evaluated by a physician. b. The changes could be related to your menstrual cycles. Keep track of the changes in the mass each month. c. The lump is probably nothing to worry about because it has been present for years and was determined to be noncancerous 5 years ago. d. Because you are experiencing no pain and the size has not changed, you should continue to monitor the lump and return to the clinic in 3 months.

a. Because of the change in consistency of the lump, it should be further evaluated by a physician.

The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for developing breast cancer? a. Black b. White c. Asian d. American Indian

a. Black

A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3 C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget disease c. Plugged milk duct d. Mammary duct ectasia

a. Mastitis

The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? Select all that apply. a. Nontender mass b. Dull, heavy pain on palpation c. Rubbery texture and mobile d. Hard, dense, and immobile e. Regular border f. Irregular, poorly delineated border

a. Nontender mass d. Hard, dense, and immobile f. Irregular, poorly delineated border

The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is: a. On the same day every month. b. Daily, during the shower or bath. c. One week after her menstrual period. d. Every year with her annual gynecologic examination.

a. On the same day every month.

The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include: a. Slowed gastrointestinal motility. b. Hyperstimulation of the salivary glands. c. Increased sensitivity to spicy and aromatic foods. d. Decreased gastrointestinal absorption causing esophageal reflux.

a. Slowed gastrointestinal motility.

The nurse is palpating a female patients breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders

a. Supine with the arms raised over her head

During an examination, the nurse notes a supernumerary nipple just under the patients left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. This variation is normal and not a significant finding. b. This finding is significant and needs further investigation. c. A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correcta supernumerary nipple is actually a mole that happens to be located under the breast.

a. This variation is normal and not a significant finding.

The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? a. Woman whose nipples are in different planes (deviated). b. Woman whose left breast is slightly larger than her right. c. Nonpregnant woman whose skin is marked with linear striae. d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin.

a. Woman whose nipples are in different planes (deviated).

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a. Abdominal tone is increased. b. Abdominal musculature is thinner. c. Abdominal rigidity with an acute abdominal condition is more common. d. The older adult with an acute abdominal condition complains more about pain than the younger person.

b. Abdominal musculature is thinner.

During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Ask the young girl if her periods have started. b. Assess the girls weight and body mass index (BMI). c. Ask the girls mother at what age she started to develop breasts. d. Nothing; breast budding is a normal finding.

b. Assess the girls weight and body mass index (BMI).

A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find? a. Poor skin turgor b. Decreased serum albumin c. Increased lymphocyte count d. Triceps skinfold less than standard

b. Decreased serum albumin

The nurse is assessing a patient who is obese for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply. a. Fasting plasma glucose level less than 100 mg/dL b. Fasting plasma glucose level greater than or equal to 110 mg/dL c. Blood pressure reading of 140/90 mm Hg d. Blood pressure reading of 110/80 mm Hg e. Triglyceride level of 120 mg/dL

b. Fasting plasma glucose level greater than or equal to 110 mg/dL c. Blood pressure reading of 140/90 mm Hg

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurses most appropriate response to this would be: a. Dont worry about the pain; breast cancer is not painful. b. I would like some more information about the pain in your left breast. c. Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct. d. Breast pain is almost always the result of benign breast disease.

b. I would like some more information about the pain in your left breast.

In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find? a. Increase in hair growth b. Inadequate nutrient food intake c. Weight 10% to 20% over ideal d. Sore, inflamed buccal cavity

b. Inadequate nutrient food intake

A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to: a. Palpate the lump first. b. Palpate the unaffected breast first. c. Avoid palpating the lump because it could be a cyst, which might rupture. d. Palpate the breast with the lump first but plan to palpate the axilla last.

b. Palpate the unaffected breast first.

A mother and her 13-year-old daughter express their concern related to the daughters recent weight gain and her increase in appetite. Which of these statements represents information the nurse should discuss with them? a. Dieting and exercising are necessary at this age. b. Snacks should be high in protein, iron, and calcium. c. Teenagers who have a weight problem should not be allowed to snack. d. A low-calorie diet is important to prevent the accumulation of fat.

b. Snacks should be high in protein, iron, and calcium.

A patient tells the nurse that his food simply does not have any taste anymore. The nurses best response would be: a. That must be really frustrating. b. When did you first notice this change? c. My food doesnt always have a lot of taste either. d. Sometimes that happens, but your taste will come back.

b. When did you first notice this change?

During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Immediately contact the physician to report the discharge. b. Ask her if she is possibly pregnant. c. Ask the patient some additional questions about the medications she is taking. d. Immediately obtain a sample for culture and sensitivity testing.

c. Ask the patient some additional questions about the medications she is taking.

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Breasts should always be symmetric. b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. c. Asymmetry is not unusual, but the nurse should verify that this change is not new. d. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.

c. Asymmetry is not unusual, but the nurse should verify that this change is not new.

A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem flat and flabby. The nurses best reply would be: a. This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues. b. This is a normal change that occurs as women get older and is due to the increased levels of progesterone during the aging process. c. Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging. d. Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help prevent the changes in elasticity and size.

c. Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging.

Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? a. Decreasing the amount of carbohydrates to prevent lean muscle catabolism b. Increasing the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis c. Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass d. Increasing the number of calories she is eating because of the increased energy needs of the older adult

c. Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass

During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate? a. The best time to examine your breasts is during ovulation. b. Examine your breasts every month on the same day of the month. c. Examine your breasts shortly after your menstrual period each month. d. The best time to examine your breasts is immediately before menstruation.

c. Examine your breasts shortly after your menstrual period each month.

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurses best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Ignore it. Benign breast enlargement in men is not unusual. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician.

Which of these conditions is due to an inadequate intake of both protein and calories? a. Obesity b. Bulimia c. Marasmus d. Kwashiorkor

c. Marasmus

A 54-year-old man comes to the clinic with a horrible problem. He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true? a. Breast masses in men are difficult to detect because of minimal breast tissue. b. Breast cancer in men rarely spreads to the lymph nodes. c. One percent of all breast cancers occurs in men. d. Most breast masses in men are diagnosed as gynecomastia.

c. One percent of all breast cancers occurs in men.

A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests? a. The risks of undernutrition should be included. b. Offer methods to reduce the stress in her life. c. Provide information regarding a diet low in saturated fat. d. This condition is hereditary; she can do nothing to change the levels.

c. Provide information regarding a diet low in saturated fat.

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. Whether the inversion is a recent change should be determined. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.

c. Whether the inversion is a recent change should be determined.

The nurse has palpated a lump in a female patients right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 oclock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation? a. Shape of the lump b. Consistency of the lump c. Size of the lump d. Whether the lump is solitary or multiple

c. Size of the lump

During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask? a. Is the rash raised and red? b. Does it appear to be cyclic? c. Where did the rash first appearon the nipple, the areola, or the surrounding skin? d. What was she doing when she first noticed the rash, and do her actions make it worse?

c. Where did the rash first appear on the nipple, the areola, or the surrounding skin?

For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity? a. Calorie count of nutrients b. Anthropometric measures c. Complete physical examination d. Measurement of weight and weight history

d. Measurement of weight and weight history

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region. b. Inspect and palpate in the epigastric region. c. Auscultate and percuss in the inguinal region. d. Percuss and palpate the midline area above the suprapubic bone

d. Percuss and palpate the midline area above the suprapubic bone

When assessing a patients nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that: a. Are in excess of daily body requirements. b. Provide for the minimum body needs. c. Provide for daily body requirements but do not support increased metabolic demands. d. Provide for daily body requirements and support increased metabolic demands.

d. Provide for daily body requirements and support increased metabolic demands.

The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: a. Bend over and touch her toes. b. Lie down on her left side and notice any retraction. c. Shift from a supine position to a standing position, and note any lag or retraction. d. Slowly lift her arms above her head, and note any retraction or lag in movement.

d. Slowly lift her arms above her head, and note any retraction or lag in movement.

During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to: a. Enlarged liver. b. Enlarged spleen. c. Distended bowel. d. Excessive diarrhea.

a. Enlarged liver.

A nurse notices that a patient has ascites, which indicates the presence of: a. Fluid. b. Feces. c. Flatus. d. Fibroid tumors.

a. Fluid.

How should the nurse document mild, slight pitting edema the ankles of a pregnant patient? a. 1+/0-4+ b. 3+/0-4+ c. 4+/0-4+ d. Brawny edema

a. 1+/0-4+ If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? a. Blacks b. Whites c. American Indians d. Hispanics

a. Blacks According to the American Heart Association, the prevalence of hypertension is higher among Blacks than in other racial groups.

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: a. Claudication. b. Sore muscles. c. Muscle cramps. d. Venous insufficiency.

a. Claudication Intermittent claudication feels like a cramp and is usually relieved by rest within 2 minutes. The other responses are not correct.

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse would teach the group which point about this procedure? a. Do the exam on the same day every month. b. Do the exam 7 days after the start of the menstrual cycle. c. Examine the left breast with the left hand and vice versa. d. Use the tips of the fingers to increase the likelihood of feeling lumps.

a. Do the exam on the same day every month. Women who are postmenopausal are taught to do BSE on the same day every month. Before menopause, women would do the procedure 7 days after the start of the menstrual cycle, when the breasts are least tender. Each breast is examined with the opposite hand. The pads of the fingers, not the fingertips, would be used for palpation. The client may use a circular, up and down, or wedge method of assessment. Consistency of use of the same method is more important than the actual method used

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Tympany c. Resonance d. Hyperresonance

a. Dullness

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants

a. Dullness across the abdomen

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? a. Mitral area b. Right atrium c. Right ventricle d. Pulmonic valve

a. Mitral area The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apical pulse. S1 (lub) and S2 (dub) would be distinguished. The pulse would be counted for a full minute. The right atrium, right ventricle, and pulmonic valve areas will not provide clear auscultation of the apical pulse.

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. No need to worry. Most men your age develop hernias. b. A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles. c. A hernia is the result of prenatal growth abnormalities that are just now causing problems. d. Ill have to have your physician explain this to you.

b. A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

The component of the conduction system referred to as the pacemaker of the heart is the: a. Atrioventricular (AV) node. b. Sinoatrial (SA) node. c. Bundle of His. d. Bundle branches.

b. Sinoatrial (SA) node. Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heart.

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? a. Lymph flow is propelled by the contraction of the heart. b. The flow of lymph is slow, compared with that of the blood. c. One of the functions of the lymph is to absorb lipids from the biliary tract. d. Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.

b. The flow of lymph is slow, compared with that of the blood. The flow of lymph is slow, compared with flow of the blood. Lymph flow is not propelled by the heart but rather by contracting skeletal muscles, pressure changes secondary to breathing, and contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves; therefore, flow is one way from the tissue spaces to the bloodstream.

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: a. The largest quadrant of the breast. b. The location of most breast tumors. c. Where most of the suspensory ligaments attach. d. More prone to injury and calcifications than other locations in the breast.

b. The location of most breast tumors.

A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurses best response? Tell the mother that: a. Breast development is usually fairly symmetric and that the daughter should be examined right away. b. She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls. c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal. d. It is unusual for breasts that are first developing to feel tender because they havent developed much fibrous tissue.

c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal.

When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: a. Mitral and tricuspid. b. Tricuspid and aortic. c. Aortic and pulmonic. d. Mitral and pulmonic.

c. Aortic and pulmonic. The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? a. Spleen b. Sigmoid c. Appendix d. Gallbladder

c. Appendix

During a routine office visit, a patient takes off his shoes and shows the nurse this awful sore that wont heal. On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, welldefined edges, and no drainage. The nurse should assess for other signs and symptoms of: a. Varicosities. b. Venous stasis ulcer. c. Arterial ischemic ulcer. d. Deep-vein thrombophlebitis.

c. Arterial ischemic ulcer. Arterial ischemic ulcers occur at the toes, metatarsal heads, heels, and lateral ankle and are characterized by a pale ischemic base, well-defined edges, and no bleeding.

. In performing an assessment of a womans axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular

c. Central, lateral, pectoral, and subscapular

The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment.

c. Consider this a delayed capillary refill time, and investigate further. Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique? a. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it. b. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations. c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. d. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. The correct technique for auscultating the carotid artery for bruits involves the nurse lightly applying the bell of the stethoscope over the carotid artery at three levels. While listening, the nurse asks the patient take a breath, exhale, and briefly hold it. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotid arteries. Examining only one carotid artery at a time will avoid compromising arterial blood flow to the brain. Pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope, should be avoided.

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin of the lower leg

d. Brownish discoloration to the skin of the lower leg A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ______ profile. a. Flat b. Convex c. Bulging d. Concave

d. Concave

When auscultating over a patients femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits: a. Are often associated with venous disease. b. Occur in the presence of lymphadenopathy. c. In the femoral arteries are caused by hypermetabolic states. d. Occur with turbulent blood flow, indicating partial occlusion.

d. Occur with turbulent blood flow, indicating partial occlusion. A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.

The community health nurse is instructing a group of young clients about breast self-examination. The nurse would instruct the clients to perform the examination at which time? a. At the onset of menstruation b. Every month during ovulation c. Weekly at the same time of day d. One week after menstruation begins

d. One week after menstruation begins The breast self-examination needs to be performed regularly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

When assessing a patients pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: a. Alternans. b. Bisferiens. c. Bigeminus. d. Paradoxus.

d. Paradoxus. In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiration and is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds: a. Are usually loud, high-pitched, rushing, and tinkling sounds. b. Are usually high-pitched, gurgling, and irregular sounds. c. Sound like two pieces of leather being rubbed together. d. Originate from the movement of air and fluid through the large intestine.

b. Are usually high-pitched, gurgling, and irregular sounds.

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

a. Intraluminal valves ensure unidirectional flow toward the heart. Blood moves through the veins by (1) contracting skeletal muscles that proximally milk the blood; (2) pressure gradients caused by breathing, during which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

The nurse is assessing the abdomen of a pregnant woman who is complaining of having acid indigestion all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea. b. Pyrosis. c. Dysphagia. d. Constipation.

b. Pyrosis.

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? a. Number of pack-years b. Desire to quit smoking c. Brand of cigarettes used d. Number of past attempts to quit smoking

a. Number of pack-years The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information is of no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking-cessation plan with the client.

The sac that surrounds and protects the heart is called the: a. Pericardium. b. Myocardium. c. Endocardium. d. Pleural space.

a. Pericardium. The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid.

A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and immediately report these. d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth

a. She can expect her areolae to become larger and darker in color.

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder

a. Spleen

A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that: a. The girl began to develop breasts. b. Her mother developed breasts. c. She began to develop pubic hair. d. She began to develop axillary hair.

a. The girl began to develop breasts.

During a cardiovascular assessment, the nurse knows that a thrill is: a. Vibration that is palpable. b. Palpated in the right epigastric area. c. Associated with ventricular hypertrophy. d. Murmur auscultated at the third intercostal space.

a. Vibration that is palpable. A thrill is a palpable vibration that signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding? a. Waves of loud gurgles auscultated in all four quadrants b. Low-pitched swishing auscultated in one or two quadrants c. Relatively high-pitched clicks or gurgles auscultated in all four quadrants d. Very high-pitched, loud rushes auscultated especially in one or two quadrants

a. Waves of loud gurgles auscultated in all four quadrants Although frequency and intensity of bowel sounds vary, depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyper-peristalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyper-resonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI? Select all that apply. a. Ethnicity b. Abnormal lipids c. Smoking d. Gender e. Hypertension f. Diabetes g. Family history

b. Abnormal lipids c. Smoking e. Hypertension f. Diabetes Nine modifiable risk factors for MI, as identified by a recent study, include abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol use, and regular physical activity.

When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? a. Document the finding. b. Auscultate the site for a bruit. c. Check for calf pain. d. Check capillary refill in the toes.

b. Auscultate the site for a bruit If a pulse is weak or diminished at the femoral site, then the nurse should auscultate for a bruit. The presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct.

The nurse is watching a new graduate nurse perform auscultation of a patients abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. We need to determine the areas of tenderness before using percussion and palpation. b. Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation. c. Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination. d. Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.

b. Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: a. Bell of the stethoscope at the base with the patient leaning forward. b. Bell of the stethoscope at the apex with the patient in the left lateral position. c. Diaphragm of the stethoscope in the aortic area with the patient sitting. d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.

b. Bell of the stethoscope at the apex with the patient in the left lateral position. The S4 is a ventricular filling sound that occurs when the atria contract late in diastole and is heard immediately before the S1. The S4 is a very soft sound with a very low pitch. The nurse needs a good bell and must listen for this sound. An S4 is heard best at the apex, with the person in the left lateral position.

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: a. Valvular disorder. b. Blood flow turbulence. c. Fluid volume overload. d. Ventricular hypertrophy.

b. Blood flow turbulence. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally, none is present.

During an assessment, the nurse uses the profile sign to detect: a. Pitting edema. b. Early clubbing. c. Symmetry of the fingers. d. Insufficient capillary refill.

b. Early clubbing The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? a. Hard and fixed cervical nodes b. Enlarged and tender inguinal nodes c. Bilateral enlargement of the popliteal nodes d. Pelletlike nodes in the supraclavicular region

b. Enlarged and tender inguinal nodes The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.

The nurse knows that during an abdominal assessment, deep palpation is used to determine: a. Bowel motility. b. Enlarged organs. c. Superficial tenderness. d. Overall impression of skin surface and superficial musculature.

b. Enlarged organs.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds.

b. Examine the tender area last.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds.

b. Examine the tender area last.

Which of the following statements is true regarding the internal structures of the breast? The breast is made up of: a. Primarily muscle with very little fibrous tissue. b. Fibrous, glandular, and adipose tissues. c. Primarily milk ducts, known as lactiferous ducts. d. Glandular tissue, which supports the breast by attaching to the chest wall.

b. Fibrous, glandular, and adipose tissues.

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? a. Increase in resting heart rate b. Increase in systolic blood pressure c. Decrease in diastolic blood pressure d. Increase in diastolic blood pressure

b. Increase in systolic blood pressure With aging, an increase in systolic blood pressure occurs. No significant change in diastolic pressure and no change in the resting heart rate occur with aging. Cardiac output at rest is does not changed with aging.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: a. Palpate the artery in the upper one third of the neck. b. Listen with the bell of the stethoscope to assess for bruits. c. Simultaneously palpate both arteries to compare amplitude. d. Instruct the patient to take slow deep breaths during auscultation.

b. Listen with the bell of the stethoscope to assess for bruits. If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery, which could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided, and excessive vagal stimulation could slow down the heart rate, especially in older adults. Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain.

The nurse is preparing to auscultate for heart sounds. Which technique is correct? a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex c. Listening to the sounds only at the site where the apical pulse is felt to be the strongest d. Listening for all possible sounds at a time at each specified area

b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex Auscultation of breath sounds should not be limited to only four locations. Sounds produced by the valves may be heard all over the precordium. The stethoscope should be inched in a rough Z pattern from the base of the heart across and down, then over to the apex; or, starting at the apex, it should be slowly worked up. Listening selectively to one sound at a time is best.

During an assessment, the nurse notices that a patients left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? a. Venous stasis b. Lymphedema c. Arteriosclerosis d. Deep-vein thrombosis

b. Lymphedema Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and lymphedema can impede drainage of lymph. The other responses are not correct.

The nurse is reviewing an assessment of a patients peripheral pulses and notices that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse? a. Bounding b. Normal c. Weak d. Absent

b. Normal When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication

b. Person who has been on bed rest for 4 days People who undergo prolonged standing, sitting, or bed rest are at risk for venous disease. Hypercoagulable (not anticoagulated) states and vein-wall trauma also place the person at risk for venous disease. Obesity and the late months of pregnancy are also risk factors.

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? a. Excessive swelling of the lymph nodes b. Presence of palpable lymph nodes c. No palpable nodes because of the immature immune system of a child d. Fewer numbers and a smaller size of lymph nodes compared with those of an adult

b. Presence of palpable lymph nodes Lymph nodes are relatively large in children, and the superficial ones are often palpable even when the child is healthy.

A patient complains of leg pain that wakes him at night. He states that he has been having problems with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed a sore on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing: a. Pain related to lymphatic abnormalities. b. Problems related to arterial insufficiency. c. Problems related to venous insufficiency. d. Pain related to musculoskeletal abnormalities.

b. Problems related to arterial insufficiency. Night leg pain is common in aging adults and may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: a. Lymphedema. b. Raynaud disease. c. Deep-vein thrombosis. d. Chronic arterial insufficiency

b. Raynaud disease. The condition with episodes of abrupt, progressive tricolor changes of the fingers in response to cold, vibration, or stress is known as Raynaud disease.

The direction of blood flow through the heart is best described by which of these? a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle

b. Right atrium, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, left ventricle Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it is then returned to the left atrium through the pulmonary vein. The blood goes from there to the left ventricle and then out to the body through the aorta.

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b. Test for Murphy sign c. Assess for rebound tenderness d. Iliopsoas muscle test

b. Test for Murphy sign

The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.

b. The patient is asked to bend his or her knees to the side in a froglike position. To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.

During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel heavy in the calf and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? a. Deep-vein thrombophlebitis b. Varicose veins c. Lymphedema d. Raynaud phenomenon

b. Varicose veins Superficial varicose veins are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins. Varicose veins are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are observed on assessment.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patients skin is warm and capillary refill time is normal. Next, the nurse should: a. Check for the presence of claudication. b. Refer the individual for further evaluation. c. Consider this finding as normal, and proceed with the peripheral vascular evaluation. d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

c. Consider this finding as normal, and proceed with the peripheral vascular evaluation. Palpating the ulnar pulses is not usually necessary. The ulnar pulses are not often palpable in the normal person. The other responses are not correct.

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Regular lub, dub pattern c. Swishing, whooshing sound d. Steady, even, flowing sound

c. Swishing, whooshing sound When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: a. Right ventricular hypertrophy. b. Increased volume and size of the heart as a result of pregnancy. c. Displacement of the heart from elevation of the diaphragm. d. Increased blood flow through the internal mammary artery.

c. Displacement of the heart from elevation of the diaphragm. Palpation of the apical impulse is higher and more lateral, compared with the normal position, because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.

A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. Ill be sleeping great, and then I wake up and feel like I cant get my breath. The nurses best response to this would be: a. When was your last electrocardiogram? b. Its probably because its been so hot at night. c. Do you have any history of problems with your heart? d. Have you had a recent sinus infection or upper respiratory infection?

c. Do you have any history of problems with your heart? Paroxysmal nocturnal dyspnea (shortness of breath generally occurring at night) occurs with heart failure. Lying down increases the volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.

A patient is having difficulty swallowing medications and food. The nurse would document that this patient has: a. Aphasia. b. Dysphasia. c. Dysphagia. d. Anorexia.

c. Dysphagia

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. Gallbladder disease. b. Overuse of laxatives. c. Gastrointestinal bleeding. d. Localized bleeding around the anus.

c. Gastrointestinal bleeding.

During a cardiovascular assessment, the nurse knows that an S4 heart sound is: a. Heard at the onset of atrial diastole. b. Usually a normal finding in the older adult. c. Heard at the end of ventricular diastole. d. Heard best over the second left intercostal space with the individual sitting upright.

c. Heard at the end of ventricular diastole. An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. The S4 occurs just before the S1.

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? a. Is easily palpable; pounds under the fingertips. b. Has greater than normal force, then suddenly collapses. c. Is hard to palpate, may fade in and out, and is easily obliterated by pressure. d. Rhythm is regular, but force varies with alternating beats of large and small amplitude.

c. Is hard to palpate, may fade in and out, and is easily obliterated by pressure. A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _______ the left leg. a. Venous obstruction of b. Claudication due to venous abnormalities in c. Ischemia caused by a partial blockage of an artery supplying d. Ischemia caused by the complete blockage of an artery supplying

c. Ischemia caused by a partial blockage of an artery supplying Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.

A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of: a. Ovary infection. b. Liver enlargement. c. Kidney inflammation. d. Spleen enlargement.

c. Kidney inflammation.

The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique would the nurse perform next? a. Palpate the abdomen for size. b. Palpate the liver at the right rib margin. c. Listen to bowel sounds in all four quadrants. d. Percuss the right lower abdominal quadrant.

c. Listen to bowel sounds in all four quadrants. The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse would listen for bowel sounds.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: a. Pulsations of the renal arteries. b. Pulsations of the inferior vena cava. c. Normal abdominal aortic pulsations. d. Increased peristalsis from a bowel obstruction.

c. Normal abdominal aortic pulsations

The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient? a. Enlarged, warm, and tender nodes b. Lymphadenopathy of the cervical nodes c. Palpable firm, small, shotty, mobile, and nontender lymph nodes d. Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue

c. Palpable firm, small, shotty, mobile, and nontender lymph nodes Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, and tender nodes indicate a current infection.

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? a. Hormonal changes causing vasodilation and a resulting drop in blood pressure b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding needs to be reported to the primary health care provider (PHCP)? a. Absence of a bruit b. Concave, midline umbilicus c. Pulsation between the umbilicus and the pubis d. Bowel sound frequency of 15 sounds per minute

c. Pulsation between the umbilicus and the pubis The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and needs to be reported to the PHCP. Bruits normally are not present. The umbilicus would be in the midline with a concave appearance. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? a. Waves of loud gurgles auscultated in all four quadrants b. Low-pitched swishing auscultated in one or two quadrants c. Relatively high-pitched clicks or gurgles auscultated in all four quadrants d. Very high-pitched loud rushes auscultated especially in one or two quadrants

c. Relatively high-pitched clicks or gurgles auscultated in all four quadrants Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be more high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds.

When assessing a client's liver during an assessment, the nurse would palpate which abdominal quadrant? a. Left upper quadrant b. Left lower quadrant c. Right upper quadrant d. Right lower quadrant

c. Right upper quadrant The liver is located in the right upper quadrant of the abdomen; therefore, the locations in the remaining options are incorrect.

The electrical stimulus of the cardiac cycle follows which sequence? a. AV node SA node bundle of His b. Bundle of His AV node SA node c. SA node AV node bundle of His bundle branches d. AV node SA node bundle of His bundle branches

c. SA node AV node bundle of His bundle branches Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly, allowing the atria the time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

In assessing a patients major risk factors for heart disease, which would the nurse want to include when taking a history? a. Family history, hypertension, stress, and age b. Personality type, high cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, diabetes, and high cholesterol d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol

c. Smoking, hypertension, obesity, diabetes, and high cholesterol To assess for major risk factors of coronary artery disease, the nurse should collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100 mg/dL or known diabetes mellitus, obesity, any length of hormone replacement therapy for post menopausal women, cigarette smoking, and low activity level.

The nurse is preparing to perform an abdominal examination on a client. The nurse would place the client in which position for this examination? a. Left lateral position b. Supine with the head and feet flat c. Supine with the head raised slightly and the knees slightly flexed d. Semi-Fowler's position with the head raised 45 degrees and the knees flat

c. Supine with the head raised slightly and the knees slightly flexed During the abdominal examination, the client lies supine (flat on the back) with the head raised slightly and the knees slightly flexed. This position relaxes the abdominal muscles. Left lateral position is a side-lying position and would not adequately expose the abdomen for examination. Placing the head and feet flat would result in the abdominal muscles being taut. The abdomen cannot be accurately assessed if the head is raised 45 degrees.

Which of these statements describes the closure of the valves in a normal cardiac cycle? a. The aortic valve closes slightly before the tricuspid valve. b. The pulmonic valve closes slightly before the aortic valve. c. The tricuspid valve closes slightly later than the mitral valve. d. Both the tricuspid and pulmonic valves close at the same time.

c. The tricuspid valve closes slightly later than the mitral valve. Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? a. To measure the rate of lymphatic drainage b. To evaluate the adequacy of capillary patency before venous blood draws c. To evaluate the adequacy of collateral circulation before cannulating the radial artery d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

c. To evaluate the adequacy of collateral circulation before cannulating the radial artery A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness. b. Resonance, dullness, and tympany. c. Tympany, hyperresonance, and dullness. d. Resonance, hyperresonance, and flatness.

c. Tympany, hyperresonance, and dullness.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe

d. Lateral to the extensor tendon of the great toe The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. No pulse is palpated at the lateral malleolus.

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6° F (37° C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question would the nurse ask the client first? a. "Do you exercise regularly?" b. "Are you considering trying to lose weight?" c. "Is there a history of diabetes mellitus in your family?" d. "When was the last time you had your blood pressure checked?"

d. "When was the last time you had your blood pressure checked?" The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors.

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination.

d. Consider this finding as normal, and proceed with the examination.

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a. Increased salivation. b. Increased liver size. c. Increased esophageal emptying. d. Decreased gastric acid secretion.

d. Decreased gastric acid secretion.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? a. Assess the patients abdomen, and notice any tenderness. b. Carefully assess the cervical lymph nodes, and check for any enlargement. c. Ask additional health history questions regarding any recent ear infections or sore throats. d. Examine the patients lower arm and hand, and check for the presence of infection or lesions.

d. Examine the patients lower arm and hand, and check for the presence of infection or lesions. The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? a. Third left intercostal space at the midclavicular line b. Fourth left intercostal space at the sternal border c. Fourth left intercostal space at the anterior axillary line d. Fifth left intercostal space at the midclavicular line

d. Fifth left intercostal space at the midclavicular line The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. Loud continual hum. b. Peritoneal friction rub. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds.

d. Hyperactive bowel sounds.

A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, Am I normal? I dont seem to need a bra yet, but I have some friends who do. What if I never get breasts? The nurses best response would be: a. Dont worry, you still have plenty of time to develop. b. I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow. c. You will probably get your periods before you notice any significant growth in your breasts. d. I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.

d. I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.

The nurse is assessing a client with a history of cardiac valve problems. Where would the nurse place the stethoscope to hear the first heart sound (S1) the loudest? a. Over the second intercostal space at the left sternal border b. Over the fourth intercostal space at the right sternal border c. Over the second intercostal space at the right sternal border d. Over the fifth intercostal space in the left midclavicular line

d. Over the fifth intercostal space in the left midclavicular line The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.

A patients abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. Obese. b. Herniated. c. Scaphoid. d. Protuberant.

d. Protuberant.

Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon

d. Sigmoid colon

A 65-year-old patient remarks that she just cannot believe that her breasts sag so much. She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause: a. Only women with large breasts experience sagging. b. Sagging is usually due to decreased muscle mass within the breast. c. A diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. Your breast milk is immediately present after the delivery of your baby. b. Breast milk is rich in protein and sugars (lactose) but has very little fat. c. The colostrum, which is present right after birth, does not contain the same nutrients as breast milk. d. You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy.

d. You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy.