Unit 3: Regional Examinations Review Questions
The nurse palpates a fine, round, mobile, nontender nodule and suspects that it is A.a fibroadenoma. B.a cyst. C.a fibrocystic breast change. D.breast cancer.
A.a fibroadenoma.
Gynecomastia may occur in an older male secondary to A.testosterone deficiency. B.lymphatic engorgement. C.trauma. D.decreased activity level.
A.testosterone deficiency.
Peau d'orange appearance is highly suggestive of which of the following? A.Breast cancer B.Gynecomastia C.Papillomas D.Colostrum
A.Breast cancer
A 45-year-old male has been admitted to the hospital with suspicion of PE. Which of the following symptoms should the nurse report to the primary health practitioner immediately? Chest pain Shortness of breath Respirations 20 breaths/min Productive cough
Chest pain
During history taking, a patient reports cramping in his calf when walking a few blocks. He states that it goes away when he sits down for a few minutes. How would the nurse document this symptom? A.Intermittent claudication B.Rest pain C.Poikilothermia D.Venous stasis
A.Intermittent claudication
When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved? A.Liver B.Spleen C.Sigmoid colon D.Kidney
A.Liver
A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? A.Murphy sign B.Psoas sign C.Rovsing sign D.Obturator sign
A.Murphy sign
Progressive hearing loss associated with aging is known as: a. diplopia b. presbycusis c. xerostomia d. anosmia
b. presbycusis
The nurse knows that the floor of the mouth is highly vascular and therefore a good location for which of the following? A. Absorption of sublingual medications B. Identification of malignancy in the pharyngeal fossa C. Infection with streptococcus D. Aspiration, even if the gag reflex is present
A. Absorption of sublingual medications
Which of the following teaching points would the nurse emphasize related to eye health? A. Always wear eye protection for occupational exposures. B. Eat a diet high in animal protein and dairy. C. Exercise five times a week for at least 20 minutes. D. Get at least 7 hours of sleep each night.
A. Always wear eye protection for occupational exposures.
Which of the following patients is most likely to have hearing loss? A. Caucasian man older than 70 years of age B. Hispanic woman older than 50 years of age C. Asian man younger than 30 years of age D. African American girl younger than 10 years of age
A. Caucasian man older than 70 years of age
While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next? A. Document this finding as normal. B. Tell the patient that this finding is unexpected. C. Report to the physician a suspicion of a slow-growing goiter. D. Look for signs of hypothyroidism.
A. Document this finding as normal.
A fair-skinned, blonde, 18 year old woman is at the clinic for skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching? (Select all that apply) A. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer B. Apply sunscreen or sunblock at least 15 to 30 minutes before sun exposure C. Avoid sun exposure between 10 AM and 4 PM to reduce UVA and UVB exposure D. A mild sunburn is acceptable in a fair skinned blonde person
A. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer B. Apply sunscreen or sunblock at least 15 to 30 minutes before sun exposure C. Avoid sun exposure between 10 AM and 4 PM to reduce UVA and UVB exposure
Risk factors for hearing loss include which of the following? Choose all that are correct. A. Frequent ear infections B. Being current on immunizations C. Exposure to smoke D. Decreased age
A. Frequent ear infections C. Exposure to smoke.
During routine physical examination of a 20-year-old female, the nurse notes a septal perforation. This finding may be significant for which of the following causes? A. Illicit drug use B. Nose picking C. Nasal trauma D. Bifid uvula
A. Illicit drug use
A 62-year-old female comes to the clinic with an exacerbation of asthma. Which of the following findings indicate a diagnosis of asthma? Select all that apply. A. Increased wheezing B. Coarse rhonchi C. Fever T 38°C orally D. Oxygen saturation 90%
A. Increased wheezing D. Oxygen saturation 90%
Which of the following statements describes the cardiovascular system most accurately? A. It is a double pump circulating blood out to the lungs and body. B. It has a heart with six chambers, great vessels, and valves. C. It includes concepts of pre-contractility, post-contractility, and load. D. It functions with a conduction system that starts in the ventricles.
A. It is a double pump circulating blood out to the lungs and body.
While evaluating the inguinal lymph nodes of a patient, the nurse palpates a 1-cm (about ½-in.) soft and freely movable node. What action should the nurse take next? A.Nothing—this finding is normal. B.Refer this patient to a specialist. C.Immediately check the patient's dorsalis pedis pulse. D.Refer the patient for immediate management of a life-threatening condition.
A.Nothing—this finding is normal.
A nurse observes a skin lesion with well defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmentated, and non-palpable. What is the correct terminology for this lesion? A. Patch B. Plaque C. Papule D. Macule
A. Patch
While examining the patient's lymph nodes, the nurse finds enlarged nodes located in front of the mastoid bone. The nurse documents enlargement of which nodes? A. Preauricular nodes B. Occipital nodes C. Superficial cervical nodes D. Supraclavicular nodes
A. Preauricular nodes
While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action? A. Recognize that it is not common to palpate lymph nodes in this region and that they must be carefully evaluated. B. Recognize that enlarged lymph nodes in this area indicate sinus inflammation. C. Recognize that this is a common area for lymph nodes to be enlarged with minor infections. D. Recognize that a palpable lymph node in this region is always indicative of malignancy.
A. Recognize that it is not common to palpate lymph nodes in this region and that they must be carefully evaluated.
A 24 year old patient reports an itchy red rash under her breasts. Examination reveals large, reddened moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions? A. Satellite B. Discrete C. Confluent D. Zosteriform
A. Satellite
The nurse is teaching an 18-year-old female, who does not use tobacco or consume alcohol, health promotion related to the head and neck. The nurse includes teaching about which of the following? (Select all that apply.) A. Seatbelt use B. Refraining from texting while driving C. Wearing a helmet D. Cancers of the neck
A. Seatbelt use B. Refraining from texting while driving C. Wearing a helmet
When assessing a patient with atelectasis, what assessment findings are expected? Select all that apply. A. Shortness of breath B. Decreased breath sounds C. Decreased oxygen saturation D. Increased tactile fremitus E. Hyperresonance
A. Shortness of breath B. Decreased breath sounds C. Decreased oxygen saturation D. Increased tactile fremitus
An 83 year old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation? A. Thinning of the skin B. Increased skin turgor C. Hypopigmented flat macules and patches over sun-exposed areas D. Multiple purplish bruises on the arms and legs
A. Thinning of the skin
Cues of hearing loss include which of the following? Choose all that are correct. A. Using a loud or monotonous voice B. Asking to repeat questions C. Concentrating on lip movement D. Leaning forward to hear
A. Using a loud or monotonous voice B. Asking to repeat questions C. Concentrating on lip movement D. Leaning forward to hear
A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. Which of the following infectious illnesses does the nurse suspect? A. Varicella B. Measles C. Roseola D. Herpes Simplex
A. Varicella
The inner ear A. contains the malleus, incus, and stapes. B. conducts sound waves to the external ear. C. translates sound to the nerves and brainstem. D. provides the body with proprioception
A. contains the malleus, incus, and stapes. this is wrong but its what the book says
The function of the ear is for A. hearing and equilibrium. B. equilibrium and perforations. C. perforations and balance. D. balance and equilibrium.
A. hearing and equilibrium.
The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of A. the loss of accommodation. B. anisocoria. C. amblyopia. D. asthenopia.
A. the loss of accommodation.
Risk factors for nose, sinus, mouth, and throat problems include A. topical decongestant use, smoking, and allergies. B. smoking, allergies, and high blood cholesterol. C. allergies, high blood cholesterol, and topical decongestant use. D. high blood cholesterol, topical decongestant use, and smoking.
A. topical decongestant use, smoking, and allergies.
When the nurse assesses a 78-year-old patient with pneumonia, what is the priority assessment?Breath sounds Airway patency Respiratory rate Percussion sounds
Airway patency
Which assessment findings would indicate that inhaled bronchodilators have been effective? A. Expiratory wheezing, O2 saturation 94%, pallor B. Vesicular breath sounds, O2 saturation 96%, pink C. Bronchial breath sounds, O2 saturation 100%, erythema D. Crackles, O2 saturation 90%, circumoral cyanosis
B. Vesicular breath sounds, O2 saturation 96%, pink
Which of the following patients would require immediate nursing care? A. An 8-year-old girl with pink conjunctivae and drainage B. A 20-year-old man with sudden visual loss after playing football C. A 52-year-old woman with clouding of vision D. A 77-year-old man with loss of vision in his peripheral fields
B. A 20-year-old man with sudden visual loss after playing football
The ABCDEs of melanoma identification do not include A. Asymmetry: one half does not match the other half B. Birthmark: cafe au lait spot that does not fade C. Color: pigmentation is not uniform; there may be shades of tan, brown, and black as well as red, white, and blue D. Diameter: greater than 6 mm E. Evolving: any change in size, shape, color, elevation - or new symptom such as bleeding, itching, or crusting
B. Birthmark: cafe au lait spot that does not fade
The cranial nerves involved with eye movement include A. II, V, and VII. B. III, IV, and VI. C. IV, V, and VIII. D. V, VI, and VII.
B. III, IV, and VI.
The nurse assesses the response of the eye to light and documents normal findings as A. PEERLA. B. PERRLA C. PERLLA. D. PERLAA.
B. PERRLA
A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion? A. Papule B. Pustule C. Cyst D. Vesicle
B. Pustule
A 40-year-old female presents with symptoms of hypothyroidism. What signs and symptoms are most consistent with a patient who has hypothyroidism? A. Slightly obese, perspiring female, who complains of feeling cold all the time and having diarrhea B. Slightly obese female with periorbital edema, who complains of cold intolerance, brittle hair, and dry skin C. Thin, anxious-appearing female with exophthalmos and a rapid pulse and who complains of diarrhea D. Thin, perspiring female with a deep hoarse voice, facial edema, a thick tongue, and reports of diarrhea
B. Slightly obese female with periorbital edema, who complains of cold intolerance, brittle hair, and dry skin
A public health nurse is performing annual vision screening for residents in senior housing. Which of the following charts would the nurse most likely be using? A. Allen chart B. Snellen chart C. Ishihara cards D. Confrontation cards
B. Snellen chart
While reviewing laboratory values for thyroid function in an adult patient, the nurse sees that the TSH is elevated, and T3 and T4 are decreased. The nurse recognizes that these findings are indicative of A. normal thyroid function. B. hypothyroidism. C. hyperthyroidism. D. thyroid cancer.
B. hypothyroidism.
The nurse has assessed the nose and documents expected findings as A. nose asymmetrical with clear drainage. B. nose symmetrical and midline. C. nose asymmetrical and proportional to facial features. D. nose symmetrical with yellow drainage.
B. nose symmetrical and midline.
A patient with diabetes mellitus who closely monitors and controls her blood glucose level is very interested in preventing complications of her illness. Which teaching is a priority for the patient related to peripheral vascular circulation? A.How to count calories. B.How to assess her feet daily. C.Choosing complex carbohydrates D.Identifying venous insufficiency.
B.How to assess her feet daily.
A dorsalis pedis of +1/4 may indicate A.DVT. B.PAD. C.Raynaud disease. D.Lymphadenopathy.
B.PAD.
A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? A.Listen for a fluid wave B.Percuss the abdomen for shifting dullness C.Auscultate for lymph nodes D.Stroke the abdomen to elicit the abdominal reflex
B.Percuss the abdomen for shifting dullness
Which of the following peripheral vascular diseases is not known to have a hereditary component? A.Lymphadenopathy B.Raynaud disease C.Abdominal aortic aneurysm D.PAD
B.Raynaud disease
A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? A.How often do you have a bowel movement? B.What was your bowel pattern before you noticed the change? C.Is there a family history of irritable bowel syndrome? D.Have any of your parents or siblings had cancer of the colon?
B.What was your bowel pattern before you noticed the change?
When assessing the lower extremities, it is critical that the examiner A.starts at the feet. B.compares side to side. C.evaluates the venous system and then the arterial system. D.starts at the femoral area.
B.compares side to side.
It is important to examine the upper outer quadrant of the breast because it is A.more prone to injury and calcifications. B.where most breast tumors develop. C.where most of the suspensory ligaments attach. D.the largest quadrant of the breast.
B.where most breast tumors develop.
A 22 year old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion? A. Crust B. Luchenification C. Keloid D. Scale
C. Keloid
The nurse is assessing the nares to evaluate the site of epistaxis. The most common site of bleeding is which of the following? A. Ostiomeatal complex B. Nasal septum C. Kiesselbach plexus D. Woodruff plexus
C. Kiesselbach plexus
Physical examination of a patient reveals an enlarged tender tonsillar lymph node. What action would the nurse take next? A. Assess for meningitis. B. Assess for dietary changes. C. Assess for an infection upstream. D. Assess for enlarged nodes in other regions.
C. Assess for an infection upstream.
The nurse is admitting a 75 year old man with a 50 year history of smoking 1 pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is A. Pitting B. Thickening and discoloration of the nail bed C. Clubbing D. Brittleness and cracking of the nails
C. Clubbing
When working with an older adult, what would the nurse emphasize as increased risks for the patient? A. Myopia and strabismus B. Blepharitis and chalazion C. Glaucoma and cataracts D. Exophthalmos and presbyopia
C. Glaucoma and cataracts
When assessing hydration, the nurse will A. Pinch a fold of skin on the medial aspect of the forearm and observe for recoil to normal B. Pinch a fold of skin on the abdomen and observe for recoil to normal C. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal D. Pinch a fold of the skin on the head and allow for skin to recoil in children
C. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal
Which of the following is part of the upper gastrointestinal tract? A. Nasal septum B. Sinuses C. Throat D. Adenoids
C. Throat
Peripheral vision is evaluated by the nurse using the A. corneal light test. B. cover test. C. confrontation test. D. cardinal fields of gaze test.
C. confrontation test.
The nurse assesses the child with purulent, unilateral nasal discharge. The nurse knows that the most likely causative factor is A. allergic rhinitis. B. choanal atresia. C. foreign body in nose. D. cystic fibrosis.
C. foreign body in nose.
Tinnitus is described as A. inability to hear well. B. dizziness. C. ringing in the ear. D. ear pain
C. ringing in the ear.
The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient A. clench their teeth during muscle palpation. B. bring their head to the chest. C. turn their head against resistance. D. extend their arms against resistance.
C. turn their head against resistance.
Which of the following is a normal ABI? A.56 B.87 C.1.0 D.24
C.1.0
When examining the breast of a 75-year-old woman, the nurse would expect to find which of the following? A.Enlarged axillary lymph nodes B.Multiple large firm lumps C.A granular feel to the breast tissue D.Pale areola
C.A granular feel to the breast tissue
A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain? A.Inspection with indirect lighting B.Iliopsoas muscle sign C.Indirect percussion for CVA tenderness D.Blumberg sign
C.Indirect percussion for CVA tenderness
When performing an abdominal assessment, what is the correct sequence? A.Inspection, palpation, percussion, auscultation B.Palpation, percussion, inspection, auscultation C.Inspection, auscultation, percussion, palpation D.Auscultation, inspection, palpation, percussion
C.Inspection, auscultation, percussion, palpation
When teaching the breast self-examination, the nurse should inform the woman that it is best to perform the exam is which of the following times? Select all that apply. A.Just before the menstrual period B.Just after the menstrual period C.On the 4th to 7th days of the menstrual cycle D.On the 10th day of the menstrual cycle
C.On the 4th to 7th days of the menstrual cycle
A history of smoking has an extremely significant role in the development of which of the following? A.Venous insufficiency B.DVT C.PAD D.Raynaud disease
C.PAD
When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? A.Right renal artery B.Right femoral artery C.Right iliac artery D.Abdominal aorta
C.Right iliac artery
A 23-year-old nulliparous woman is concerned that her breasts seem to change in size all month long and they are very tender around the time she has her period. The nurse should explain to her that A.nonpregnant women usually do not have these breast changes and this is cause for concern. B.breasts often change in response to stress, so it is important to assess her life stressors. C.cyclical breast changes are normal. D.breast changes normally occur during pregnancy and she should have a pregnancy test.
C.cyclical breast changes are normal.
The seven Ps of an acute arterial occlusion include A.polythermia. B.popliteal pallor. C.poikilothermia. D.pitting edema.
C.poikilothermia.
The correct position in which to place the patient to palpate the breasts is A.left lateral position with arm over head. B.sitting forward with hands on hips. C.supine with arm over head. D.supine with arms at side.
C.supine with arm over head.
Which of the following scores for distance vision indicates the patient with the poorest vision? A. 200/20 B. 18/20 C. 24/20 D. 20/100
D. 20/100
The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral assessment is important because of the increased risk for which of the following A. Fordyce granules B. Pharyngitis C. Anosmia D. Candida albicans
D. Candida albicans
Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field? A. Blind spots B. Ptosis C. Halos D. Floaters
D. Floaters
All of the following skin lesions may be papular except A. Warts B. Acne C. Nevi D. Herpes Zoster
D. Herpes Zoster
Which of the following differentiates the RN assessment from the APRN assessment? A. History and risk factors B. Symptom analysis C. Inspection and palpation D. Otoscopic assessment
D. Otoscopic assessment
Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach? A. Please tilt your head back as far as possible. B. Please turn your head as far to the right as you can. C. Please bring your chin down toward your neck. D. Please tilt your head slightly down and to one side.
D. Please tilt your head slightly down and to one side.
A patient presents with a complaint of drooping of the eyelid on one side. This finding is documented as which of the following? A. Kernig sign B. Pharyngitis C. Thyroglossal cyst D. Ptosis
D. Ptosis
Acute airway obstruction is a situation that should be A. reassessed during the next visit. B. evaluated within 8 hours. C. further assessed thoroughly. D. quickly assessed and treated.
D. quickly assessed and treated.
Which assessment technique best confirms splenic enlargement? A.Deep palpation under the left costal margin B.Fist percussion of the spleen with the patient in a sitting position C.Deep palpation over the RUQ with the patient lying on the right side D.Percussion along the left MAL spleen and gentle palpation
D.Percussion along the left MAL spleen and gentle palpation
A patient reports swelling in her ankles. How would the nurse proceed with physical examination? A.Have the patient elevate her feet to better visualize her ankles. B.Measure her ankles at their widest point. C.Evaluate further for the brown hyperpigmentation associated with venous insufficiency. D.Press the fingers in the edematous area evaluating for a remaining indentation after the nurse removes his or her fingers.
D.Press the fingers in the edematous area evaluating for a remaining indentation after the nurse removes his or her fingers.
What percussion sound is heard over most of the abdomen? A.Resonance B.Hyperresonance C.Dullness D.Tympany
D.Tympany
A male patient presents to the clinic with a complaint of a hard, irregular, nontender mass on his chest under the areola. Upon examination, the nurse notes that the mass is immobile and suspects A.gynecomastia. B.benign lesion. C.Paget disease. D.carcinoma.
D.carcinoma.
A patient with benign breast condition is likely to A.develop breast cancer later in life. B.require hormone replacement therapy. C.be a teenager. D.have it resolve after menopause.
D.have it resolve after menopause.
When the nurse assesses a client with respiratory symptoms, which of the following complaints should be evaluated first? Chest soreness Dyspnea Cough Sputum
Dyspnea
A 3-year-old child is brought to the ED with stridor, nasal flaring, intercostal and supraclavicular retractions, and respiratory rate of 40 breaths/min. What type of situation is this? Stable Acute Urgent Emergency
Emergency
A 92-year-old female with a history of COPD presents with increasing shortness of breath, wheezing, no sputum, and 5-lb weight gain in 1 week. What is the most likely problem? Impaired breathing Impaired airway clearance Activity intolerance Overweight
Impaired breathing
Which of the following factors is the most significant risk factor for COPD? Increased age Immune suppression Tobacco smoking Occupational exposure
Tobacco smoking
Which of the following are appropriate interventions for the patient who is at risk for ear infection? Select all that apply. a. Be current on immunizations. b. Avoid secondhand smoke. c. Clean only external ear. d. Have audiogram yearly
a. Be current on immunizations. b. Avoid secondhand smoke. c. Clean only external ear.
The nurse auscultates a medium-loud whooshing sound that softens between S1 and S2. The nurse documents this finding as which of the following? a. Grade III systolic murmur b. Grade I systolic murmur c. Grade V diastolic murmur d. Grade II diastolic murmur
a. Grade III systolic murmur
When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is a. S1 greater than S2. b. S1 is equal to S2. c. S2 greater than S1. d. no S1 is heard.
a. S1 greater than S2.
The nurse auscultates an extra sound on a patient 1 week after an MI. It is immediately after S2 and is heard best at the apex. Which of the following does the nurse suspect? a. S3 gallop b. S4 gallop c. Systolic ejection click d. Split S2
a. S3 gallop
The nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. The nurse interprets this as a. a normal finding over the trachea. b. a normal finding over the bronchi. c. an abnormal finding over the lung. d. an abnormal finding over the trachea.
b. a normal finding over the bronchi.
An adolescent male presents with complaints of nosebleeds. The nurse would further assess for a. hemangioma. b. nasal trauma. c. angiofibroma. d. cystic fibrosis.
b. nasal trauma.
A patient who visits the clinic has the controllable risk factors of smoking, high-fat diet, overweight, decreased activity, and high BP. What concept should the nurse use when performing patient teaching? a. Teach the patient the most serious information. b. Give the patient brochures to review before the next visit. c. Discuss risk factors that the patient is interested in modifying. d. Describe consequences of risk factors to motivate the patient.
c. Discuss risk factors that the patient is interested in modifying.
The nurse assesses the neck vessels in the stable patient with heart failure to determine which of the following? a. The bilateral carotid pulse b. The presence of bruits c. The highest level of jugular venous pulsation d. The strength of the jugular veins
c. The highest level of jugular venous pulsation
In a healthy patient, the myocardial cells in the ventricle depolarize and contract during a. prediastole. b. diastole. c. systole. d. postsystole
c. systole.
Which of the following clusters of symptoms are common in females preceding an MI? a. Chest pain, nausea, diaphoresis b. Weight gain, edema, nocturia c. Dizziness, palpitations, low pulse d. Fatigue, difficulty sleeping, dyspnea
d. Fatigue, difficulty sleeping, dyspnea
A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis? a. Impaired tissue perfusion (myocardial) b. Impaired cardiac output c. Impaired gas exchange d. Fluid imbalance, excess
d. Fluid imbalance, excess
The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority? a. Auscultate heart sounds. b. Inspect the precordium. c. Percuss the left border. d. Obtain pulse and BP.
d. Obtain pulse and BP.
Which of the following is an outcome appropriate for a patient with hearing impairment? a. Provide a communication board or picture to assist teaching. b. Minimize background noise and close door. c. Stand in front of patient and explain procedure. d. Patient explains plan to accommodate hearing impairment.
d. Patient explains plan to accommodate hearing impairment.
