HA exam 3

the nurse is performing an abdominal assessment. following auscultation of the abdomen, what action should the nurse perform next action?

light percuss over all 4 quadrants

the nurse is assessing an alert and independent aging adult client's nutritional status. which is the most appropriate initial question?

"can you tell me the food that you ate yesterday?"

the nurse obtains subjective data while assessing a patient that presents with suspected heart failure. what questions should the nurse ask related to the patient's sleep-rest pattern? select all that apply.

"how many pillows do you need to sleep at night?" "how long does take you to fall asleep?" "do you need to sleep upright in a chair?"

the nurse is providing care to an aging adult client with cardiovascular disease. the client states. "if only i had changed my lifestyle when I was young, I would not have developed this disease." what response by the nurse would indicate an understanding of this disease process?

"your lifestyle and age a role in the development of this disease"

the nurse is assessing a client's pulse, and feels a pulse that is hand to palpate, fades in and out, easily obliterated by pressure. the nurse documents this pulse as:

1+ weak

which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly?

2

a nurse is providing care to an aging adult with a history of heart failure and peripheral vascular disease. the client is unable to stand or ambulate. the nurse should implement measures to prevent what complications?

DVT

which abdominal assessment finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment?

absent bowel sounds

while auscultating a client's heart sounds, the nurse hears an extra heart sound immediately before the first heart sound (S1). An audible S4 would be considered an expected finding in what client?

an aging adult

a client is diagnosed with valvular insufficiency. using the diagram, the nurse should identify which valve when teaching the client about the health problems? (heart picture)

aortic

the nurse is assessing the base of a client's heart. what are the valve closures that can be best heard at the base of the heart?

aortic and pulmonic

the nurse has the client participate in the assessment technique shown. for which health problem is the nurse assessing in this client?

ascites

a client's history includes long term treatment for arthritis and atherosclerosis. during a follow up visit, the nurse finds that the patient has upper gastrointestinal bleeding. which medication in the client's prescriptions may be responsible for this condition?

aspirin

the nurse is preparing to palpate the posterior tibial pulse. at which location would the nurse expect to palpate?

behind the ankle

the nurse is planning to teach a community group about cardiovascular health. the nurse notes which ethnic group has the highest prevalence of heart disease and stroke in the US?

black/african americans

the nurse is performing an assessment on a 50 year old female client. the client reports experiencing flu-like symptoms for the past month which include cold sweats, nausea, and light headiness. she asks the nurse, "could those be signs of a heart attack?" which of the following is the best response by the nurse?

explain to the client that her symptoms are "typical" for menopause which is part of the normal aging process

an aging adult presents to a clinic for a routine physical examination. the nurse reviews the client's medical record and notes a progressive increase in systolic blood pressure. what action should the nurse take?

explain to the client that is a normal age related change

a nurse is collecting subjective data from a client. the nurse reports having episodes of occasional temporary loss of consciousness. the nurse documents this as

synocope

when assessing a client with valve issue, the nurse palpates a fine vibrations over the precordium. the nurse documents this finding as:

thrill

the nurse is unable to palpate the dorsalis pedis pulse on an older adult client. which of the following would be most appropriate for the nurse to do next?

use Doppler ultrasonography to locate the pulse

the nurse is preparing to auscultate a client's pericardium. which of the following statements is true regarding the diaphragm of the stethoscope?

use the diaphragm to listen for high pitched sounds

a nurse preparing a client for a local community group on a coronary heart disease. which of the following recommendations would the nurse include as appropriate for reducing a person's risk? select all that apply.

walk at least 30 minutes/day eat foods low in sodium use relaxation techniques to manage stress

a nurse is performing an abdominal assessment of an older adult client. when collecting and analyzing data, the nurse should be cognizant of what age related change in gastrointestinal structure and function? select all that apply

xerostornia decreased gastric mobility decreased gastric acid secretion

when assessing the carotid arteries on an aging adult male client, the nurse auscultates a bruit. the nurse should recognize the most likely cause of a carotid bruit is an aging adult is:

atherosclerosis

the nurse is providing care to a client newly admitted with known cardiovascular disease. the nurse would assess the status of the client's carotid arteries by performing with step first:

auscultating each artery at one time with the bell to assess for bruits

a client comes to the clinic with complaints of a "bump" in her armpit. the nurse notes a firm tender lymph node in the axilla. the nurse would further assess which of the following areas? select all that apply.

breast upper arm

the nurse should identify the highlighted area as which anatomic section?

bundle of his

the nurse is providing care to a client with venous insufficiency. a skin ulcer associated with venous insufficiency is most likely found on which area of the lower extremities:

calf of the leg

a client complains of swollen legs and feet. how can the nurse best initially assess the degree of edema in the lower extremities?

check for pitting

the nurse is performing an assessment on a young adult. the nurse is unable to palpate the popliteal pulses bilaterally. the next action by the nurse would be to:

continue the assessment as this is normal finding

the nurse is providing care to a client with a venous ulcer on the leg. based on the nurses' understanding of the peripheral vascular system, how should the nurse best position the client?

dangle the clients legs over the side of the bed

the nurse notes diminished bowel sounds in pregnant client. the next action taken by the nurse should be:

document this finding in the assessment

the nurse is collecting subjective data from a client. which of the following would indicate to the nurse that a client is at nutritional risk?

drinks 4 servings of beer per day

the nurse is providing care to a patient with arterial insufficiency. leg pain associated with arterial insufficiency would most likely be relieved by:

elevation of lower extremities

prior to performing an assessment of the abdomen, the nurse should first:

empty the bladder

a 35 year old man is seen in the clinic for an "infection in my left foot" which of the following would the nurse expect to find during an assessment of this client?

enlarged and tender inguinal nodes

the nurse is assessing a woman who is 27 weeks' pregnant. the client is concerned about the recent emergence of varicose veins in the back of her claves. what is the nurse's best action?

explain to the client that circulatory changes during pregnancy frequently cause varicose veins

the nurse is examining a client with congestive heart failure. the nurse would expect the client to report which symptoms:

fatigue, edema, dyspena

while obtaining objective data during the assessment of the cardiovascular system of a client, the nurse identifies that which findings will require further evaluation?

hands and feet are cold to touch capillary refill takes longer than 2 secs

a nurse is caring for a client who is a smoker with a two year history of using oral contraceptives. based the findings, the client should be assessed for which condition?

hypertension

in presenting a workshop on parameters of cardiac function, which condition should a nurse list as those most likely to lead to a increase in preload?

hypertension

a nurse has auscultated a client's abdomen and noted one or two bowel sounds in a two minute period of time. how should the nurse document the client's bowel sounds?

hypoactive

the nurse assesses the client as shown. what pulse is the nurse assessing?

if its top of the foot (dorsalis pedis) inner corner of ankle (posterior tibial)

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. which of these findings can be explained by expected hemodynamic changes related to age?

increase in systolic blood pressure

a nurse is providing care to an aging adult man. the nurse notes swelling in his ankles and jugular venous distention when he is elevated 45 degrees. the nurse interprets the cause of this finding as:

increased pressure in right side of the heart

the nurse is caring for a client who is diagnosed with Raynaud phenomenon. the nurse should plan interventions to address which nursing diagnosis?

ineffective tissuse perfusion

a 67 year old client states that he recently began to develop pain in his left calf when climbing the 10 stairs to his apartment. this pain is reflected by sitting for about 2 minutes, then he is able to resume his activities. this client is most likely experiencing

intermittent claudication

during a shift assessment, the nurse is identifying the client's apical impulse. Where should the nurse best palpate the apical impulse?

left mid-clavicular line of the chest at the fifth intercostal space

a 30 year old male client with a body mass index of 22 kg/m2 is being admitted to the hospital for elective knee surgery. which assessment finding is most important for the nurse to report to the health care provider?

liver span of 15 cm

the nurse is assessing a client with a suspected case of appendicitis, which of the following assessment finding would be most indicative of appendicitis?

nausea and vomiting

the nurse is conducting an abdominal assessment of a pregnant client. the nurse documents which of the following collected as subjective data as expected findings? select all that apply.

nausea and vomiting increased blood pressure hard stools/constipation

the nurse is conducting an abdominal assessment. the nurse would document which of the finding as an expected finding during physical assessment of the abdomen?

observation of visible pulsations in epigastric region

a client is admitted to the hospital with left upper quadrant pain. the nurse suspects which visceral organ may be a possible source of the pain?

pancreas

a client complains of a leg pain that wakes him at night. he states that he "has been having problems" with his legs. he has pain his legs when they are elevated, which disappears when he dangles them and has "a sore" on the inner aspect of the right ankle. on the basis of this history information, the client is most likely experiencing:

problems related to arterial insufficiency

the nurse performs the allen's test on a client. this test is tested by occultation in present in this artery:

radial

the nurse is performing a peripheral vascular assessment on a bedridden client. the following findings are documented. "right leg with increased warmth, swelling, redness, tenderness to palpation, and a positive homan's sign" which action should the nurse take based on the assessment findings?

seek emergency referral due to the risk of pulmonary embolism

in assessing the client with arterial insufficiency, the nurse correlates which finding with this disorder?

skin that appears thin, shiny, and taut over the lower legs

in assessing a client's major risk factors of a heart attack or MI which factors are most relevant in the history-taking or data-collected?

smoking, hypertension, obesity, high-cholesterol

in considering modifiable and non-modifiable cardiovascular risk factors, the nurse recalls that:

African americans have a higher risk for hypertension than white americans at the same age group

the nurse is caring for several clients. which of the following clients is the highest risk for development of venous disease?

a person who has been on bed rest for 4 days