Exam 3

diaphragmatic excursion

movement of the thoracic diaphragm during breathing (3-5 cm=normal)

myocardium

muscular, middle layer of the heart

cardiac cycle

A complete heartbeat consisting of contraction and relaxation of both atria and both ventricles

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. a. Patient has a history of diabetes and cigarette smoking. b. Skin of the patient is pale and cool. c. His ankles have two small, weeping ulcers. d. Patient works long hours sitting at a computer desk. e. He states that the pain gets worse when walking. f. Patient states that the pain is worse at the end of the day

A, B, E Rationale: Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset with exertion and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems.

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in a very soft voice. b. As the patient repeatedly says ninety-nine, the examiner clearly hears the words ninety-nine. c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound. e. As the patient says a long ee-ee-ee sound, the examiner hears a long aaaaaa sound.

A, C, D As a patient repeatedly says ninety-nine, normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear ninety-nine is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony. When a patient says along ee-ee-ee sound, normally the examiner also hears along ee-ee-ee sound through auscultation, which is a measure of egophony. If the examiner hears a long aaaaaa sound instead, this sound could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as one-two-three, the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patients lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved with elevation of the leg

A, D, E Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough and diminished breath sounds

A. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: a. Atelectatic crackles that do not have a pathologic cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes.

A. atelectatic crackles that do not have a pathologic cause One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

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 The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by: a. Projectile vomiting. b. Hypoactive bowel activity. c. Palpable olive-sized mass in the right lower quadrant. d. Pronounced peristaltic waves crossing from right to left

A. projectile vomiting Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis.After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

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 The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant

Upon assessing a client who underwent abdominal surgery 10 days ago, the client reports abdominal pain. Which type of pain would the client experience? A. visceral pain B. somatic pain C. referred pain D. intractable pain

A. visceral pain visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain is not curable.

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 Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct.

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. a. Test for the Murphy sign b. Test for the Blumberg sign c. Test for shifting dullness d. Perform the iliopsoas muscle test e. Test for fluid wave

B, D Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion. b. Decreased gastric acid secretion. c. Delayed gastrointestinal emptying time. d. Increased gastrointestinal emptying time

B. decreased gastric acid secretion Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.

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 With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses

Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL)

B. extend 3 to 4 cm above the inner third of the clavicles Rationale: The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

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 Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next action should be to: a. Assure the mother that these signs are normal symptoms of a cold. b. Recognize that these are serious signs, and contact the physician. c. Ask the mother if the infant has had trouble with feedings. d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

B. recognize that these are serious signs, and contact the physician. Rationale: The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infants feeding is not a priority at this time

During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: a. Costal angle. b. Sternal angle. c. Xiphoid process. d. Suprasternal notch

B. sternal angle rationale: The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back

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 Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder on to the examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration.

During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line d. Dull percussion note in the left upper quadrant at the midclavicular line

B. tympanic percussion note in the umbilical region Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally, the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line)

During a health history, the patient tells the nurse, I have pain all the time in my stomach. Its worse 2 hours after I eat, but it gets better if I eat again! Based on these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis

C. duodenal ulcer Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may relieved by more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are: a. Musical in quality. b. Usually caused by a pathologic disease. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration

C. expected near the major airways Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest

C. a normal finding in a healthy adult Rationale: The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a. A bruit is absent. b. Femoral pulses are increased. c. A pulsating mass is usually present. d. Most are located below the umbilicus.

C. a pulsating mass is usually present Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

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 The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse. a. Normal b. Absent c. Bounding d. Weak, thready

C. bounding rationale: A full, bounding pulse occurs with hyperkinetic states(e.g., exercise, anxiety, fever),anemia, and hyperthyroidism. An absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease

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

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 Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area, particularly in thin persons who have good muscle wall relaxation.

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Airway obstruction b. Emphysema c. Pulmonary consolidation d. Asthma

C. pulmonary consolidation Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony.

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 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. Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which maybe present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: a. Normally auscultated over the trachea b. Bronchial breath sounds and normal in that location. c. Vesicular breath sounds and normal in that location. d. Bronchovesicular breath sounds and normal in that location.

C. vesticular breath sounds and normal in that location Rartionale: Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where air flows through smaller bronchioles and alveoli.

A woman in her 26th week of pregnancy states that she is not really short of breath but feels that she is aware of her breathing and the need to breathe. What is the nurses best reply? a. The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath. b. The increase in estrogen levels during pregnancy often causes= a decrease in the diameter of the rib cage and makes it difficult to breathe. c. What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong. d. This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mothers body, which results in an increased respiratory rate.

C. what you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong. During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mothers body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: a. Adventitious sounds and limited chest expansion. b. Increased tactile fremitus and dull percussion tones. c. Muffled voice sounds and symmetric tactile fremitus. d. Absent voice sounds and hyperresonant percussion tones.

C.muffled voice sounds and symmetric tacile fremitus rationale: Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds

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

D. AV node SA 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

During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n): a. Normal heart. b. Systolic murmur. c. Enlargement of the left ventricle. d. Enlargement of the right ventricle

D. Enlargement of the right ventricle Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. Splenomegaly. b. Distended bladder. c. Constipation. d. Ascites.

D. ascites If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation

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 A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: a. Decreased fluid volume. b. Increased cardiac output. c. Narrowing of jugular veins. d. Elevated pressure related to heart failure

D. elevated pressure related to heart failure Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about the activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure

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 Rationale: 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.

The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem? a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal anti inflammatory drugs

D. frequent use of nonsteroidal anti-inflammatory drugs Peptic ulcer disease occurs with the frequent use of nonsteroidal anti inflammatory drugs, alcohol use, smoking, and Helicobacterpylori infection.

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 Borborygmi is the term used for hyper peristalsis when the person actually feels his or her stomach growling

endocardium

Inner layer of the heart

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 A protuberant abdomen is rounded, bulging, and stretched. A scaphoid abdomen caves inward.

pericardium

membrane enclosing the heart

barrel chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

tumor

a swelling of a part of the body, generally without inflammation, caused by an abnormal growth of tissue, whether benign or malignant.

jugular vein distention

a visual bulging of the jugular veins in the neck that can be caused by fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax

ascites

abdominal swelling caused by accumulation of fluid

scoliosis

abnormal lateral curvature of the spine

crepitus

air in subcutaneous tissue

Cheyne-stokes respiration

an irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or apnea

mediastinum

area between the lungs containing the heart, aorta, venae cavae, esophagus, and trachea

pleural friction rub

audible raspy sound

paroxysmal nocturnal dyspnea

awakening from sleep with SOB and needing to be upright to achieve comfort

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

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.

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. Rationale: 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.

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 Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing

b. friction rub A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases. Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a. Diarrhea. b. Peritonitis. c. Laxative use. d. Gastroenteritis

b. peritonitis Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: a. Pneumonia. b. Postnasal drip or sinusitis. c. Exposure to irritants at work. d. Chronic bronchial irritation from smoking.

b. postnasal drip or sinusitis A cough that primarily occurs at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

hernia

bulging of an organ or tissue through an abnormal opening

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion

c. chest pain that is worse on deep inspiration and dyspnea Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Cheyne-Stokes respirations c. Hypoventilation d. Chronic obstructive breathing

c. hypoventilation Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute

The nurse knows that auscultation of fine crackles would most likely be noticed in: a. A healthy 5-year-old child. b. A pregnant woman. c. The immediate newborn period. d. Association with a pneumothorax.

c. the immediate newborn period Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurses preliminary analysis, based on this history, is that this patient may be suffering from: a. Bronchitis. b. Pneumonia. c. Tuberculosis. d. Pulmonary edema.

c. tuberculosis Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers.

wheezes

continuous high-pitched whistling sounds produced during breathing

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have? a. Infants sleeping position b. Sibling history of eating disorders c. Amount of background noise when eating d. Presence of dyspnea or diaphoresis when sucking

d. Presence of dyspnea or diaphoresis when sucking To screen for heart disease in an infant, the focus should be on feeding. Fatigue during feeding should be noted. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic, and then falls into exhausted sleep and awakens after a short time hungry again

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 rationale: 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

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 (>10mm Hg) during inspiration and increases with expiration

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 suprapublic bone Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.

During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate? a. Croup b. Tuberculosis c. Viral infection d. Pulmonary edema

d. pulmonary edema Sputum, alone, is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema or it may be a side effect of sympathomimetic medications. Croup is associated with a barking cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.

When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

d. shape and configuration of the chest wall Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patients level of consciousness and the patients skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation

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

d. sigmoid colon rationale: The sigmoid colon is located in the left lower quadrant of the abdomen

dyspnea

difficulty breathing

dyshagia

difficulty swallowing

orthopnea

discomfort when breathing while lying flat

kyphosis

exaggerated forward rounding of the back

nocturia

excessive urination at night

crackles

fine, crackling sounds made as air moves through wet secretions in the lungs

Pyrosis

heartburn

peritonitis

inflammation of the peritoneum (lining of your abdomen)

pleuritis

inflammation of the pleura (tissue that lines the lungs and chest cavity)

gastroenteritis

inflammation of the stomach and intestines

viscera

internal organs

claudication

pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest

tympanic

pertaining to the eardrum

tachypnea

rapid breathing

precordium

region or thorax immediately in front of the heart

borborgymi

rumbling or gurgling noise made by the movement of fluid and gas in the intestines

bradypnea

slow breathing

striae

stretch marks

edema

swelling

tactile fremitus

vibration of the chest wall that results from sound vibrations created by speech or other vocal sounds

bronchophony

voice sounds increased vocal resonance with greater clarity and resonance than normal

bruit

whoosing sound in the vessels