NURS 190 Midterm for Physical Assessment 2 Questions/Answers (Complete Guide)

NURS 190 Midterm for Physical Assessment 2 1. Pt with malignant melanoma; risk factors; what will the skin look like? ABCDE ABCDE of Melanoma • Asymmetry • Border Irregularity • Color Variation • Diameter Greater than 6mm • Evolving Changes Risk Factors • Sun sensitivity, difficulty tanning, hx of prolonged sun exposure, use of tanning booths, occupational exposure to chemicals like tar and radiation QUIZ QUESTION: Nevi this big and has color variation should be alerted for? – Malignant Melanoma 2. How to assess for central cyanosis? Look at patient’s oral mucosa QUIZ QUESTION: How to assess central cyanosis? – check the oral mucosa 3. Contact dermatitis Inflammation of the skin due to an allergy to a substance that comes into contact with the skin Redness, hives, vesicles or scales accompanied by intense itching 4. 3 Tineas; signs and symptom Tinea Corporis – fungal infection of the body Tinea Capitis – fungal infection of the scalp • Need to further assess the cause of pruritus of the scalp because this can be due to lice Tinea Pedis – fungal infection of the feet (athlete’s foot) 5. COPD, configuration of chest Barrel chest; AP:T diameter is equal QUIZ QUESTION: Expected finding with patient with COPD? • Barrel chest • Kyphosis • Hollow Clavicle • Protruding Sternum  angle of Louie 6. Scoliosis, kyphosis, lordosis, torticollis Scoliosis – lateral curvature and rotation of the thoracic and lumbar spine (S back); most common in female Kyphosis – exaggerated posterior curvature of the thoracic spine (hunchback); associated with aging. Lordosis – exaggerated curvature of the lumbar spine (swayback); compensation for pregnancy, obesity, and skeletal changes. Torticollis – muscle spasm by spinal accessory nerve, causing lateral flexion contracture of neck muscle 7. Physiological changes in older adult for all the systems discussed Skin, Hair, and Nails • Decreased elasticity, sebum production, perspiration, and melanin • Increased sensitivity to light • Nails become thicker, and more brittle Head, Neck and Lymphatics • Loss of subcutaneous fat in the face • Decreased reproductive hormone • Hair change, tooth loss, limited ROM • Complaints of tired or weak feeling due to thyroid dysfunction Eye • Decreased vision acuity • Presbyopia – age-related near vision difficulty • Cataract – thickened yellow lens; decreased lens clarity • Macular Degeneration – loss of central vision Ears, Nose, Mouth and Throat • Loss of hearing frequency • Gradual hearing loss (presbycusis) • Chelitis (angular stomatitis) • Decreased sense of taste and smell, saliva production, • Receding gum, tooth loss Respiratory • Decreased respiratory efficiency, cough ability • Changes in breath depth • Increased RR, effect of infection Breast and Axillae • Limited ROM for examinations • Modification of BSE • Changes in breast tissue composition • Gynecomastia in males • Increased breast cancer risk with aging Cardiovascular • Loss of ventricular compliance and vascular rigidity • Conduction system loses automaticity Peripheral Vascular • Increased BP • Decreased pulse with irregularities • Enlarged calf vessel 8. Different types of color – jaundice, pallor etc; What requires immediate intervention Cyanosis – mottled blue color in skin (REQUIRES IMMEDIATE INTERVENTION) Pallor – loss of skin color due to the absence of oxygen Uremia – pale yellow tone due to urinary retention Erythema – redness of the skin due to increase visibility of the oxyhemoglobin Jaundice – yellow undertone due to increase bilirubin in the blood QUIZ QUESTION: CYANOSIS is a priority because it indicates hypoxemia 9. How to assess jaundice, central cyanosis? Look for discoloration with the patient’s oral mucosa, then conjunctiva next 10. How to assess temperature Use the dorsal surface of the hand and feel for the temp QUIZ QUESTION: If assessing for temperature, use the DORSAL surface of the hand 11. Sxs of infection; patient suspecting with infection Older patient with pneumonia will present CONFUSION QUIZ QUESTION: patient suspected of fungal infection? – have you taken antibiotics recently 12. Assessing for pain; expected findings with acute pain /chronic pain Self-reported pain from patient is the most accurate assessment of pain QUIZ QUESTION: Best way to assess for pain is SELF-REPORTED pain from patient 13. Cranial nerves I, II, III,IV, VI; how to assess the different cranial nerves? CN I: Olfactory – smell • Assessment: have the patient close their eyes, obstruct one nare then make patient sniff a common substance, and then do the other nare • Anosmia – inability to detect odor • Unilateral or bilateral anosmia CN II: Optic – sight • Assessment: Snelling and Rosenbaum • Optic atrophy, papilledema, amblyopia, field defects CN III: Oculomotor – eyelids and pupil • Direct Constriction – shine light directly to the pupil; failure of the pupil to constrict shows defect in the direct pupillary response; defect in CN III • Consensual Constriction – simultaneous constriction of the pupil that is not illuminated. • 6 Cardinal Fields of Gaze – evaluates the movement of the eyes o Nystagmus – weakness of the extraocular muscles; repetitive uncontrolled eye movements o Looking up and down without moving the head • Confrontational Test – tests peripheral vision by covering one eye together with patient; examiner moves finger in peripheral field • ABNORMAL: can’t move eye upward, and downward • Diplopia, ptosis, dilated pupils, inability to focus on close objects CN IV: Trochlear – eyeball • ABNORMAL: can’t move eye down or nasally • Convergent strabismus, diplopia CN VI: Abducens – eyeball • ABNORMAL: can’t move eye temporally • Diplopia, strabismus QUIZ QUESTIONS: • Test for CN II (Optic Nerve) – Snellen and Rosenbaum • CN III (Oculomotor Nerve) – look up and down without moving the head 14. Assess for clubbing Normal nails will form a diamond-shaped opening when put together; convex curve have the dorsal surface of the fingers together QUIZ QUESTION: How to assess for clubbing of fingers? – dorsal surface of fingers next to each other 15. Assessing for coordination? What tests? What is positive and negative Romberg’s Romberg’s Test • Used to test for equilibrium • Have the patient stand with feet together and arms to the side, eyes open first then closed. • Mild swaying is a NEGATIVE Romberg • If patient is unable to maintain balance or needs to have feet further apart, then there may be a problem with the vestibular apparatus (inner ear). QUIZ QUESTION: • Minimal swaying during Romberg’s test – NEGATIVE FINDING • Swaying and feet apart – POSITIVE ROMBERG 16. Assess for weber or Rinne or whisper test? Normal and abnormal findings Weber Test • Use of tuning fork; • Place activated tuning fork on top of head; sound should be heard equally (no lateralization) • Lateralization may be due to poor conduction (sound heard better in impaired ear) or nerve damage (sound is referred to the better ear) Rinne Test – use of tuning fork • Bone Conduction – tuning fork against the mastoid process • Air Conduction – tuning fork in front of the external meatus • Air conduction should be TWICE longer than Bone Conduction (AC 2x > BC) Whisper Test • Whisper a phrase or sentence from a distance and have the patient repeat it; inability to repeat phrase may indicate hearing loss; check for high frequency sounds QUIZ QUESTIONS: • Rinne Test – air conduction is twice longer than the bone conduction • Hearing Test – whisper random phrases to the patient and make them repeat it • Rinne Test – air conduction of 32 and bone conduction of 15; still normal finding, slight difference is okay. 17. Types of adventitious breath sounds and normal breath sounds NORMAL BREATH SOUNDS • Tracheal – harsh, high pitched • Bronchial – loud, high pitched • Bronchovesicular – medium loudness, medium pitch • Vesicular – soft, low pitched ADVENTITIOUS BREATH SOUNDS (ABNORMAL) • Fine Rales/Crackles – high pitched, short crackling • Coarse Rales/Crackles – loud, moist, low pitched bubbling • Wheezes – high pitched, continuous • Rhonchi – low pitched, continuous, snoring, rattling • Stridor – loud, high pitched, crowing heard without a stethoscope • Friction rub – low-pitched grating, rubbing QUIZ QUESTIONS: • Low-pitched continuous, snoring sound – RHONCHI • Asthma like symptoms -WHEEZING 18. Patient with breast cancer, mastectomy with dissection with lymph nodes; precautions? No BP on the affected arm QUIZ QUESTION: What to tell nurse during assessment? – don’t take BP on the side of mastectomy 19. Assess for orthostatic hypotension Orthostatic Hypotension – temporary drop of BP that occurs after changing positions quickly Signs: decrease in systolic by 20mmHg or diastolic by 10mmHg within 3 minutes of standing, palpitations, syncope Symptoms: dizziness, blurred vision, weakness, nausea, headache, chest pain 20. How to assess for orthopnea Orthopnea – difficulty breathing when lying down Patient may have orthopnea if they require number of pillows to prop themselves, or sit up while sleeping 21. Different types of breathing patterns Eupnea – even depth and regular pattern Tachypnea – rapid, shallow respirations; pneumonia Bradypnea – slow, regular respirations; intracranial pressure Hyperventilation – rapid, deep respirations; Kussmaul’s respiration ketoacidosis Hypoventilation – irregular, shallow respirations; narcotic OD, chest splinting Cheyne-Stokes – periods of deep breathing alternating with periods of apnea; heart failure, respiratory depression Sighing – frequent sighs; dyspnea, dizziness Biot’s Respirations (Ataxic) – shallow, deep respirations with periods of apnea; respiratory depression, brain damage Obstructive Breathing – prolonged expiration; COPD, asthma, chronic bronchitis 22. Pneumonia, pneumothorax, atelectasis Lobar Pneumonia – infection that causes fluid, bacteria, and cellular debris fill the alveoli • Signs: decreased O2 sat, bronchial breath sounds, crackles, productive cough, dullness • Symptoms: dyspnea, fatigue, chills Pneumothorax – air move into the pleural space and causes partial, or complete collapse of the lung • Signs: tracheal deviation to unaffected side, diminished or absent breath sounds, hyperresonance • Symptoms: SOB, sharp chest pain, anxiety Atelectasis– collapsed or impaired inflation of the lungs, can be due to airway obstruction • Signs: decreased or absent breath sounds, increased RR, decreased O2 sat, use of accessory muscle, wheezing, rhonchi • Symptoms: dyspnea, fatigue r/t increased work of breathing QUIZ QUESTION: chest expansion on only one side – PNEUMOTHORAX 23. Malignancy, lymph node: possible indication of malignant or benign breast cancer Common Sxs • Dimpling of the skin • Deviation of nipple • Nipple retraction • Change in shape of ONE breast • Edema • Discharge Enlargement of breast DOES NOT necessarily mean cancer because pregnancy and menstrual cycle affect the size of breasts Lymph nodes are HARD and FIXATED Benign breast or fibrocystic breast disease • Lumps, pain or tenderness, and nipple discharge QUIZ QUESTION: SATA – NO tenderness before period and breast enlargement 24. How to assess for thyroid. Normal and abnormal finding Thyroid gland should not be observable until the patient swallows Thyroid should not be palpable, not until swallowing ABNORMAL FINDINGS • HYPERthyroidism – weight loss; exophthalmos; irritable o Graves’ Disease • HYPOthyroidism – weight gain; weak and tired feeling; depressed o Myxedema, Hashimoto’s Thyroiditis QUIZ QUESTION: sign of HYPOTHYROIDISM – weight gain 25. How to assess for carotid pulse Inspect the neck for pulsations • Absence of pulsations may indicate obstruction Palpate carotid pulse one at a time located between neck and trachea • Weak thread pulse, irregular rhythm and unequal bilaterally are abnormal Auscultate carotid pulse • Should hear very quiet sound, with no swishing sounds • Bruits – swishing sounds; obstruction causing turbulence, like narrowing of vessels due to cholesterol build up • Hyperthyroidism or anemia can produce bruits 26. Landmarks for different pulses; APETM Aortic: RSB, 2nd ICS (right sternal border, 2nd intercostal space) Pulmonic: LSB, 2nd ICS (Left sternal border) Erb’s Point: LSB, 3rd ICS Tricuspid: LSB, 4th ICS Mitral/Apical: LMCL, 5th ICS (Left Midclavicular Line, 5th intercostal space) 27. How to assess for TMJ TMJ dysfunction is suspected if there’s facial pain, limited jaw movement accompanied by clicking sound as the jaw opens and closes (crepitus) QUIZ QUESTION: expected finding when examining for TMJ syndrome – CREPITUS 28. Location for precordial heart sounds; know the exact location by picture and description 29. Ataxia; how to assess if coordination is an issue? Ataxia – loss of control of body movements CN VIII (Auditory) – the vestibular nerve is responsible for equilibrium Romberg’s test to test for coordination • Have the patient stand with arms to the side with feet together • Test with eyes open, then close • Mild swaying is NEGATIVE • Need to have feet further apart, and moderate swaying are POSITIVE 30. Sxs of peripheral artery disease; early and late signs Arterial Insufficiency – inadequate circulation in the arterial system due to fatty plaque; pain in the thigh, calf, or buttocks (claudication) • Sxs: claudication, rubor, cool, shiny skin, diminished pulses Arterial Aneurysm – bulging or dilation caused by weakness in wall of an artery 31. What is A fib? Characteristics, subjective and objective findings; What is a complication? Dysrhythmic atrial contraction with no regularity of pattern Results to poor blood flow Sxs: confusion, fatigue, heart palpitations, SOB, weakness Complications: stroke, heart failure 32. Pulse deficit; how to measure; nursing interventions? Apical pulse > Carotid pulse  pulse deficit Both pulses should be synchronous 33. Sxs asthma and COPD Asthma – chronic hyperreactive condition, resulting in bronchospasm, mucous edema, and increased mucous secretion • Signs: wheezing, diminished breath sounds, increased RR, use of accessory muscle, decreased O2 sat • Symptoms: dyspnea, anxiety, chest pain COPD – barrel chest, SOB 34. Irregular pulse, radial, carotid, etc, what to do? Measure apical pulse for a full minute QUIZ QUESTION: absent pedal pulse – use DOPPLER ULTRA SOUND 35. Sxs of DVT Deep Vein Thrombosis – occlusion of a deep vein, such as the femoral, or pelvic circulation, by a clot. Obj: unilateral edema, low-grade fever, tachycardia Subj: absence of symptoms; pain along iliac crest, popliteal space or calf muscle; increase pain with sharp dorsiflexion of the foot (Homan’s sign) 36. Patient with AV fistula, what is being assessed? And how to assess Arteriovenous Fistula – abnormal connection between an artery and vein, commonly caused by piercing injuries like stab, and gunshot wounds Obj: machinery murmur, bulging veins near the surface of the skin, decreased BP, increased HR, HF, cyanosis, clubbing of fingers Subj: fatigue, SOB, dizziness, and lightheadedness 37. Restraints Check for pulse, cap refill  NEUROVASCULAR CHECK Assess q 2 hours Provide hydration and assist with elimination Tie the restraint onto the moveable part of the bed UAP can help but RN should ASSESS 38. How to assess for strabismus Cover/Uncover Test • Uncovered eyes should be fixated when the other eye is covered o Movement of the uncovered eye (strabismus) signifies weakness Strabismus – eyes do not align simultaneously under normal condition • Exophoria – one eye outwards • Esophoria – one eye inwards QUIZ QUESTION: strabismus – cover/uncover test 39. Cardinal fields of gaze, normal and abnormal Evaluates eye movement and eye muscles (CN III) Presence of nystagmus could mean weakness of CN III QUIZ QUESTION: jerking movement of the eye when doing the 6 cardinal fields of gaze -NYSTAGMUS 40. Direct pupillary and consensual response Direct pupillary response – illuminated pupil should constrict Consensual pupillary response – pupil not illuminated should constrict simultaneously with the illuminated eye Tests CN III 41. Cover uncover test Uncovered eye should be fixated Strabismus signifies weakness of CN III 42. Corneal light reflex Twinkle in the eye The reflection of light in both eyes should be located in the same spot QUIZ QUESTION: corneal light reflex – light reflection is seen on the same spot on the eye 43. Snellen vs Rosenbaum chart; how to interpret the result 20/20 or 14/14 Snellen Chart – used to test for DISTANT VISION; normal finding should be 20/20 Rosenbaum Chart – used to test for NEAR VISION; normal finding should be 14/14 Numerator – distance from the chart Denominator – distance a person with normal vision can read the last line For patient with corrective lenses – test them with and without the lenses QUIZ QUESTION: 20/80 – you would see at 20 feet what a person with normal vision would see at 80 feet. 44. How to asses for ptosis and Astigmatism Ptosis – drooping of the eyelids due to cranial nerve damage or systemic neuromuscular weakness Astigmatism – refraction of light is spread over a wide area rather than on a distinct point on the retina 45. Percussion different sounds on body parts/organs Tympany – loud, high-pitched, drum-like sound • Gastric bubble or air-filled intestines Resonance – loud, low-pitched hollow tone of long duration Hyperresonance – longer than resonance • Lungs with trapped air Dullness – high-pitched tone that is soft and short duration Flatness – high-pitched tone, very soft and shorter than dullness • Solid tissue, muscle, bone QUIZ QUESTION: high-pitched drum like – TYMPANY 46. How to assess for lymph nodes Lymph nodes should not be palpable if they are not inflamed QUIZ QUESTION: lymph node are not palpable – NORMAL FINDING 47. BSE for post-menopausal and child bearing Post-menopausal BSE – every month same time, since no more menstrual period Child bearing – check 5 days after period begins, same time every month QUIZ QUESTION: BSE Teaching – do it in the shower with soapy water 48. Thrill, heave, murmur, bruits, Thrills – soft vibratory sensation Heave – feels like abnormally large beating of heart Bruit – loud blowing sound Murmur – harsh blowing sound caused by disruption of blood flow 49. Carotid stenosis vs tricuspid stenosis; sounds difference? Carotid Stenosis – bruits Tricuspid Stenosis – rumbling low-pitched heart murmur 50. Allen test? What is normal and abnormal finding? What is it for? Allen’s Test – used to determine patency of radial and ulnar arteries Block radial or ulnar artery, clench fist, palm should return to normal color If palm remains pallor, then the artery not blocked is not patent 51. Sxs of right and left HF Right Sided Heart Failure • Edema, weight gain, distended jugular vein, swelling Left Sided Heart Failure (Congestive Heart Failure) • SOB, swelling, fatigue, weakness, tachycardia, tachypnea, 52. Healthy people 2020; CV screening: target population African American and Hispanics Reducing mortalities due to coronary heart disease and stroke Promotion of CV health through enhancing awareness of risk factors Increase use of screening to identify individuals at risk 53. What is thrombophlebitis Inflammation of veins due to thrombus formation/clots 54. Location of lymph nodes Preauricular Posterior Auricular Occipital Tonsillar Submandibular Submental Superficial Cervical Deep Cervical Supraclavicular QUIZ QUESTIONS: • Picture asking to locate the lymph node under jaw – SUBMANDIBULAR • Enlarged lymph node in front of the ear – PREAURICULAR 55. Pediculosis sxs Head lice Redness of the scalp Pruritus QUIZ QUESTION: expected finding for pediculosis capitis – redness of the scalp 56. Normal finding for tympanic membrane Intact, flat, gray, translucent with no scars White patches – scars from infections Yellow reddish – infection in MIDDLE EAR Bulging – increased pressure in MIDDLE EAR Failure to visualize – cerumen impaction Retracted – vacuum in the middle ear due to blocked eustachian tube QUIZ QUESTION: exudate in the outer ear – OTITIS EXTERNA 57. Percussions (location) sinus/chest what kind Posterior thorax • Normal: resonance (long, low-pitched hollow sound) • Ab: Hyperresonance due to over inflation of lung like pneumothorax or emphysema Direct percussion on the facial sinuses QUIZ QUESTION: sinusitis – DIRECT PERCUSION 58. Grading scale for edema 1+ = 2mm 2+ = 4mm 3+ = 6mm 4+ = 8mm QUIZ QUESTION: 6mm pitting edema – 3+ 59. Grading scale for checking pulse (amplitude?) 0 = absent or nonpalpable 1 = weak 2 = normal 3 = increased 4 = bounding 60. 4 things you’re assessing for pulse (rate, rhythm, symmetry, amplitude) – what it means, grading scale for pulse Rate – the number of beats per minute Rhythm – the regularity of the beats Symmetry – pulses on both sides of body should be similar Amplitude – the strength of the beat, assessed on a scale of 0 to 4. 61. Difference between vertigo, tinnitus, pruritis Vertigo – sensation of whirling and loss of balance Tinnitus – ringing of the ear Pruritus – itching; increase in incidence with age, usually due to dry skin, 62. Patient with cataracts what are the subjective/objective findings Glaucoma – the result of sudden increase in intraocular pressure resulting from blocked flow of fluid from the anterior chamber. Pupil is oval-shaped and dilated Cornea appears clouding with circumcorneal redness Pain onset is sudden and accompanied by decrease in vision and halos around lights. QUIZ QUESTION: Blurry vision and not able to distinguish colors – CATARACT 63. Patient with glaucoma & macular degeneration subjective/objective what part of vision can they see, and they can’t Gradual loss of central vision while peripheral vision remains intact The eyes are affected at different rates Risk factors include hypertension and cigarette smoking QUIZ QUESTION: loss of central vision – MACULAR DEGENERATION 64. Hyperopia, myopia, presbyopia Myopia – nearsightedness; light rays focus in front of the retina Hyperopia – farsightedness; light rays focus behind the retina Presbyopia - age-related farsightedness; inability to see things up close QUIZ QUESTIONS: • 24 y/o having difficulty reading up close – HYPEROPIA • Age-related changes in eyes – DRYNESS and PRESBYOPIA 65. Deflections of EKG, QRST, P wave, what does it mean P wave: atrial depolarization PR interval: time needed for the electric current to travel from the atria to the AV node QRS complex: ventricular depolarization QT interval: period from the beginning of ventricular depolarization to the moment of repolarization T interval: ventricular repolarization Cardiac: The nurse who works on a cardiac unit is teaching the student nurse about heart sounds. The student nurse asks how the S1 heart sound is produced. Which of the following is the nurse’s best response? 1. “It results from the closure of the semilunar valves.” 2. “It is heard when the aortic valve closes just slightly faster than the pulmonic valve.” 3. “It results from the closure of the atrioventricular valves.” 4. “It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.” Correct Answer: 3 During the focused interview, the client makes the following statements. Which of the following statements indicates that the client has an increased risk of developing cardiovascular disease? 1. “I was diagnosed with hypothyroidism about 5 years ago.” 2. “My doctor always tells me when I come in that my blood pressure is low.” 3. “I know my grandmother had diabetes, but every time it has been checked mine has been normal.” 4. “My total cholesterol has always been around 170.” Correct Answer: 1 The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. The nurse requests information about how he felt during the time of the myocardial infarction. Which of the following client statements would be unexpected? 1. “I couldn’t catch my breath.” 2. “My chest didn’t actually ever hurt.” 3. “My wife said I looked like someone poured water all over me.” 4. “I got so sick to my stomach.” Correct Answer: 2 The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the client’s coronary arteries. Which of the following questions by the nurse has the highest priority to help the nurse determine the client’s most important risk factor for this condition? 1. “Can you please tell me about the vitamins or supplements that you take?” 2. “Have you ever been diagnosed with rheumatic fever?” 3. “Do you smoke or are you exposed to secondhand smoke?” 4. “Have you ever had a diagnostic test, such as an electrocardiogram, stress test, or echocardiogram, or a surgical procedure for a cardiovascular problem?” Correct Answer: 3 The nurse is preparing to assess the client’s cardiovascular system. Which of the following positions will the nurse need to place the client in during the assessment? Standard Text: Select all that apply. 1. Dorsal recumbent 2. Leaning forward 3. Right lateral position 4. Left lateral position 5. Sitting upright Correct Answer: 1,2,4,5 The student nurse is assessing the client’s cardiovascular system while the experienced nurse observes. The employment of which of the following techniques by the student nurse indicate the need for further education? Select all that apply. 1. The client complains of discomfort while lying flat. The student nurse auscultates the client’s chest quickly while the client continues to lie flat. 2. The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line. 3. The student nurse examines the client’s legs and notes that the client’s hair is evenly distributed. 4. The student nurse gently palpates the client’s carotid arteries simultaneously to determine pulse strength, rhythm, and rate. 5. The student nurse examines the client’s hands and fingers and notes the presence of clubbing. Correct Answer: 1,4 The nurse is percussing the client’s anterior chest and notes a dull sound over an area where lung tissue is normally found. Which of the following would the nurse associate with this finding? 1. This is a normal finding. 2. The client’s heart may be enlarged. 3. The client has developed a murmur. 4. The client has a pulse deficit.Correct Answer: 2 The nurse is performing a cardiac assessment on a 70-year- old client admitted with hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the point of maximal impulse. The nurse suspects that the client may have developed which of the following problems? 1. Left ventricular hypertrophy 2. Aortic stenosis 3. Right ventricular volume overload 4. Enlarged left atrium Correct Answer: 1 A 39-year- old client has been admitted to the hospital with complaints of increasing fatigue. The history is remarkable for rheumatic fever as a child. The nurse hears a diastolic murmur at the apex when the client is in the left lateral position. The murmur is described as a rumble without radiation. This description is most consistent with: 1. tricuspid regurgitation. 2. mitral regurgitation. 3. mitral stenosis. 4. pulmonic stenosis. Correct Answer: 3 During the cardiac assessment of a client, the nurse hears a loud rumbling during diastole that increases toward the end of the sound. This sound is heard with the bell of the stethoscope over the lower left sternal border. Nurse would suspect which of the following in this client? 1. Aortic stenosis 2. Tricuspid stenosis 3. Mitral regurgitation 4. Pulmonic stenosis Correct Answer: 2 The Intensive Care Unit nurse is performing a cardiac assessment on a newly admitted 72-year- old client and notes the following findings: peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45degree angle, and an enlarged liver. These findings are most consistent with which of the following disorders? 1. Pulmonary edema 2. Left-sided heart failure 3. Myocardial infarction 4. Right-sided heart failure Correct Answer: 4 The student nurse is speaking with a nurse regarding the objectives of Healthy People 2020. Which of the following statements by the student nurse indicates that the student nurse requires further education regarding these objectives? 1. “Parents of school-aged children really need to be educated about the importance of treating strep throat.” 2. “African Americans really need to be educated about the symptoms associated with hypertension.” 3. “People who smoke are twice as likely to die from a heart attack when compared to those who don’t smoke.” 4. “African Americans can benefit greatly from education aimed at increasing their understanding about the importance of exercise.” Correct Answer: 2 The Emergency Department nurse determines that the client may be having a myocardial infarction. Which of the following pieces of info indicate that the client is experiencing an acute cardiovascular problem? Select all that apply. 1. Blood pressure has dropped from normal and is 90/52. 2. Apical heart rate is 114 beats per minute. 3. Skin is flushed and warm. 4. Respiratory rate is 28 per minute. 5. The client is complaining of a headache. Correct Answer: 1,2,4 The client has been admitted to the Coronary Care Unit with a myocardial infarction. Which of the following statements by the client indicate that adequate learning has occurred? 1. “I’m just sick to my stomach because I ate something that didn’t agree with me.” 2. “I think I must have given myself a little too much insulin this morning.” 3. “I’ve been breathing fast and my heart’s been racing because my heart’s not working right.” 4. “Just give me something for the nausea and I can go home.” Correct Answer: 3 A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures. The nurse would respond with which of the following statements? 1. “Your lymph nodes filter blood for your body.” 2. “They are responsible for the break-down of old red blood cells.” 3. “They make lymphocytes for you.” 4. “Your lymph nodes help to remove infectious organisms.” Correct Answer: 4 The nursing student is learning about the appropriate method to use when assessing a client’s blood pressure. The student nurse asks the nursing instructor why it is necessary to palpate the systolic pressure prior to the procedure. Which of the following is the nursing instructor’s best response? 1. “You can document this value if you cannot hear the blood pressure well.” 2. “This needs to be done only when the client is developing clinical manifestations associated with shock.” 3. “You are more likely to get an accurate reading when you do it this way.” 4. “It is the best way to determine an arterial obstruction.” Correct Answer: 3 The student nurse is preparing to perform an assessment of the client’s peripheral vascular system. The experienced nurse asks the student nurse questions to ensure the student nurse has prepared adequately. Which of the following statements by the student nurse indicate that further education is required? Select all that apply. 1. “I need to take a blood pressure only in the client’s right arm.” 2. “The best way to assess the carotid pulses is palpate one side and then the other.” 3. “It will be easier to assess the client’s carotid pulses if the client is obese.” 4. I should inspect the arms to ensure that they are close to the same size.” 5. “I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions.” Correct Answer: 1,3 The nursing student is learning about blood pressure assessment and asks the instructor about blood pressure values. Which of the following responses is an accurate response? 1. “A normal blood pressure always depends on the client’s previous values.” 2. “A normal blood pressure is below 140/90.” 3. “A client with prehypertension has a blood pressure that is greater than 140/90.” 4. “A client with stage II hypertension has a blood pressure that is greater than 160/100.” Correct Answer: 4 The nurse examines the peripheral vascular system of a client diagnosed with chronic bronchitis 22 years ago. The nurse examines the client’s hand. Which of the following statements by the client is consistent with the client’s diagnosis? 1. “My fingers look so pointy and narrow at the ends.” 2. “My fingernails are as hard as a rock.” 3. “My nails always look a little bluish.” 4. “My nails have a lot of strange ridges in them.” Correct Answer: 3 The nurse is documenting about an ulcer on the lateral aspect of the client’s right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. To help determine information about the origin of the client’s ulcer, which of the following pieces of the assessment will be most useful for the nurse? 1. Skin turgor 2. Calf measurements 3. Homan’s sign 4. Peripheral pulses Correct Answer: 4 The nurse is completing an assessment on a client following a cardiac catheterization procedure. During the initial assessment, the nurse easily palpates the client’s right dorsalis pedis and posterior tibial pulses. The pulses on the client’s left leg are strong and easily palpable. During the next assessment, the nurse is unable to palpate or find these pulses on the right side with a Doppler. Which is the most appropriate action for the nurse at this time? 1. Notify the healthcare provider immediately. 2. Assess for the client’s right popliteal pulse. 3. Take the client’s blood pressure. 4. Place the client in Trendelenburg position. Correct Answer: 2 The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery. Which of the following tests may be used to help determine the patency of this artery? 1. Trendelenburg test 2. Manual compression test 3. Homan’s sign 4. Allen’s test Correct Answer: 4 A female client being examined by the nurse exhibits 2+ pitting edema in the right arm, while the left arm is normal in size. Which of the following responses by the nurses is most important at this time? 1. “How much salt do you have in your diet?” 2. “Does the other arm swell also?” 3. “Tell me about your past surgical procedures.” 4. “Do you ever feel self-conscious about your arm?” Correct Answer: 3 A 31-year- old female client wishes to begin taking oral contraceptives. The medical history indicates that the client had a DVT three years ago. After reviewing the objectives set forth in Healthy People 2020, which of the following is the best response by the nurse? 1. “We can have the healthcare provider write you a prescription today.” 2. “You will also have to take blood thinners.” 3. “I need to perform a Homan’s test on you.” 4. “Taking oral contraceptives increases your risk of developing clots.” Correct Answer: 4 The nurse is conducting a wellness presentation for a group of factory employees and notes a large number of African Americans present. Based on information included in Healthy People 2020, the nurse would choose which of the following topics as a priority for this setting? 1. Cancer risk reduction 2. Bone density assessments 3. Smoking cessation 4. Blood pressure screening Correct Answer: 4 OTHER CHAPTERS: The nurse is preparing to assess a client’s abdomen. Which of the following sequences will the nurse use to assess this body area? 1. Percussion, Palpation, Auscultation, Inspection 2. Auscultation, Inspection, Palpation, Percussion 3. Inspection, Palpation, Percussion, Auscultation 4. Inspection, Auscultation, Percussion, Palpation Correct Answer: 4 The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. The nurse should use which of the following techniques to put the client at ease when assessing the client’s abdomen? 1. Palpate known painful areas first. 2. Touch each area lightly before applying deeper palpation. 3. Perform the exam as quickly as possible. 4. Refrain from conversation during the assessment. Correct Answer: 2 The nurse is assessing an adult client when suddenly the client refuses to continue the examination. What is the nurse’s next step? 1. Give the client a short break and then resume the assessment. 2. Document what was done and what was refused. 3. Summon another nurse to the room to serve as a witness. 4. Enlist the assistance of the client’s family to encourage the rest of the assessment. Correct Answer: 2 The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. The nurse would correctly document this finding as which of the following? 1. Uremia 2. Cyanosis 3. Jaundice 4. Carotenemia Correct Answer: 3 The nurse is caring for a client who has smoked for many years and documents that “clubbing is present.” Which of the following techniques is the best way for the nurse to determine the presence of clubbing? 1. Place two thumbs touching side-by- side. 2. Place two of the same fingers from each hand together. 3. Place two index fingers together tip-to- tip. 4. Place the hands out straight with the palm sides down. Correct Answer: 2 The nurse is inspecting the fingernails of a client with a diagnosis of polycythemia. Which of the following findings would be expected with this diagnosis? 1. Dark red nails 2. Horizontal white bands 3. Pale nail beds 4. Spoon-shaped nails Correct Answer: 1 The nurse is caring for a client complaining of a painful, hot area located on the client’s leg. Erythema and edema are present in the localized area. Which of the following actions should the nurse perform next? 1. Palpate the area. 2. Place a heating pad on the area. 3. Notify the healthcare provider. 4. Place client on bed rest. Correct Answer: 3 The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client’s left arm. The client states, “I had a burn here a long time ago, but it seemed to keep on getting bigger.” The nurse would correctly document this finding in which of the following ways? 1. Ulcer 2. Keloid 3. Fissure 4. Scar Correct Answer: 2 The nurse is performing an assessment of the client’s head and neck. The client requests information about the assessment of her lymph nodes. Which of the following is the best response? 1. “Sometimes, enlarged lymph nodes indicate an infection.” 2. “All of your lymph nodes should be easily palpable.” 3. “The lymph system makes antibiotics to treat infection.” 4. “When one lymph node is identified as being enlarged, this is always an abnormal finding.” Correct Answer: 1 During a focused interview of a client, the nurse learns about an open lesion on the client’s head that hasn’t healed in several months. What might this indicate to the nurse? 1. The client may have a thyroid disease. 2. The client may have a malignancy. 3. The client may be pregnant. 4. The client may have meningitis. Correct Answer: 2 The nurse is assessing the function of the client’s cranial nerves. The nurse finds that the client is unable to demonstrate the ability to chew. The nurse suspects that which of the following cranial nerves is not functioning properly? 1. Cranial nerve III 2. Cranial nerve V 3. Cranial nerve VII 4. Cranial nerve VI Correct Answer: 2 The nurse is auscultating the temporal artery and hears a soft blowing sound. How would the nurse correctly document this finding? 1. Bruit 2. Murmur 3. Stenosis 4. Occlusion Correct Answer: 1 The nurse notices that a client’s pupils constrict when reading the consent form for medical treatment. This observation would lead the nurse to consider which of the following? 1. The room is too dark. 2. The client is able to read. 3. This is a normal response. 4. The client requires glasses for reading. Correct Answer: 3 *There was also a question on ptosis – drooping eyelid The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to hear out of the left ear. Which of the following cranial nerves was most likely affected? 1. Cranial nerve I 2. Cranial nerve XII 3. Cranial nerve VIII 4. Cranial nerve VII Correct Answer: 3 The nurse is performing a focused interview with the client. The nurse asks the client if the client has noticed any drainage from the ears, and the client states, “Yes.” Which of the following statements indicate that the client may have developed acute otitis media? 1. “The ear canal itself is really red, raw, and sore.” 2. “I noticed that the drainage looked clear, like water.” 3. “The drainage looks like what is draining from my nose, kind of clear and mucousy.” 4. “It is kind of yellowish-reddish color.” Correct Answer: 4 The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Based on this finding, the nurse would implement which of the following actions first? 1. Administer IV fluids. 2. Provide oral hygiene. 3. Administer oxygen. 4. Provide a warm drink. Correct Answer: 3 During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. This structure can be identified by using which of the following landmarks? 1. Clavicle 2. Sternum 3. First rib 4. Vertebral column Correct Answer: 2 The client was brought to the Emergency Department. The nurse administered a breathing treatment for the client earlier. The nurse is preparing the client for a procedure. The nurse notes that the client is breathing in a shallow manner and the client’s hands are trembling. Which of the following actions will help decrease the client’s level of anxiety? 1. The nurse should explain all procedures in a calm and reassuring voice. 2. Request the immediate presence of the healthcare provider. 3. Provide oxygen for the client. 4. Postpone the procedure. Correct Answer: 1 The nurse is assessing the client’s respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which of the following terms would the nurse use to document this finding? 1. Tachypnea 2. Obstructive breathing 3. Hypoventilation 4. Cheyne-Stokes Correct Answer: 4 The nurse percusses the lungs and determines that there is an area of hyperresonance. This finding is consistent with which of the following conditions? 1. Pneumonia 2. Atelectasis 3. Pneumothorax 4. Pleural effusion Correct Answer: 3 While the client sleeps, the nurse notes that the client’s respirations periodically stop. This finding would be documented as: 1. Tachypnea. 2. Bradypnea. 3. Apnea. 4. Atelectasis. Correct Answer: 3 The nurse is preparing to assess an elderly client with emphysema. Which of the following anatomical changes would the nurse expect to find in this client? 1. Funnel chest 2. Barrel chest 3. Pigeon chest 4. Scoliosis Correct Answer: 2 The nurse is percussing the anterior chest of an elderly client. Which of the following would the nurse expect to find in this client? 1. Flatness 2. Dullness 3. Tympany 4. Hyperresonance Correct Answer: 4 A female client is hospitalized with injury and tissue destruction of the left pectoralis major and serratus anterior muscles due to a motor vehicle accident. The nurse would include which of the following information during the discharge teaching? 1. Prosthestic devices 2. Support bras 3. Plastic surgery 4. Physical therapy Correct Answer: 2 The nurse is using inspection to assess the breasts of a female client. Which of the following findings might the nurse obtain using this assessment technique? 1. Symmetry 2. Hard nodules 3. Tenderness 4. Skin consistency Correct Answer: 1 The nurse is teaching an older adult client about breast self-examination (BSE). Which of the following should the nurse provide during this instruction? Sata. 1. Additional lighting 2. Increased time 3. Opportunity for questions 4. Large-print handouts 5. A quiz at the end of the instruction Correct Answer: 1,2,3,4 The nurse is performing a breast assessment of an Asian adult female. Which of the following should the nurse do first? 1. Ask the client if she has ever had any breast disease such as cancer of the breast, fibrocystic disease, or fibroadenoma. 2. Ask the client to disrobe from the waist up and place a gown on with the opening to the front. 3. Ask the client if she has noticed any changes in her breasts such as lumps, thickening, or discharge from the nipples. 4. Ask the client how she feels about her breasts. Correct Answer: 3 1. Plurisity a. grating scratching 2. COPD: a. kyphosis prominent angle of luie, increases ap, hollow clavical area, 3. Sturnum is out of the ribcage: a. Pectum exvivatum 4. Chronic bronchitisis: a. cyanosis 5. Collapsed lung a. absent sounds on the affective side 6. Decreased chest wall expansion: a. lumbar Pneumonia b. plural effusion c. pumothorax 7. Q1 1. Nurse is assessing a child a. Gain cooperation 2. Abdominal assessment a. Inspect, auscultate, percuss, palpate 3. Nurse is doing assessment on pt with pain a. Light touch before palpating 4. Pt becomes pale and diaphoretic a. Ask about anxiety and explain procedure 5. Elevated abnormal tissue a. Keloid 6. Older adult as lesion on nose and tracks of mouth a. Ulcerated 7. Edema +1 a. Slightly 8. Older adult hyperpigmentation a. hyperpigmentation 9. Swishing sounds on temporal artery a. Bruit 10. Bruit in the thyroid a. Increased blood flow 11. Polycytermia vera a. Red nails 12. TMJ Syndrome a. Grinding teeth 13. Hypothyroidism a. Risk for injury due to confusion and lethargy 14. Hyper” “ a. Annual hormone check up 15. Hirsutism a. Hormonal imbalance 16. Vitiligo a. Disturbed body image 17. Hyperthyroidism a. Ask about salt 18. None palpable lymph nodes a. Normal findings 19. Pt refuses assessment a. Document 20. Yellow skin a. Jaundice 21. Angle of nail >170 a. Spoon (Clubbing) 22. TMJ what can we expect a. Nighttime teeth grinding 23. What is considered a medical emergency a. Cyanosis (jaundice, pallor, erythema) 24. Herpes a. Ulcerated (pustule) 25. Pale and diaphoretic ask if they are a. Anxiety 26. Nursing diagnosis for hypothyroidism a. Risk for injury due to confusion and lethargy? (constipation) 27. Pt refuses assessment a. Document what has been done and what has been refused 28. Urticaria. lesions a. Confluent Lesions that run together. 29. 30. Q2 1. Nurse is assessing tympanic membrane has a bluish color 31. a. Recent head trauma 32. 2. Otoscopic exam on adult 51. 52. 53. 54. 55. 56. a. Direct percussion 33. a. Pull the pinna back the reinsert 34. 15. Vision eye test (SATA) a. Frowning and squinting of eyes 3. Exam clients ears and right one was (SATA) 57. b. Accommodation pupils dilated a. Irrigation with warm oil b. A ceremen spoon to remove wax 35. 4. Romberg test is positive 36. a. Obtain bedside commode 37. 5. Child w/ cough for 3 days a. Severe nasal inflammation 16. Burned eyes/ eyelash  burning fire 58. a. Foreign bodies 59. 17. Diabetes retinopathy 60. a. Cause blindness 61. 18. 38 year old 62. 38. 6. Teenagers in hs chewing tobacco 39. a. Ulcerations on the lip on tongue 40. 7. Nosebleeds for the past 2 days a. age 63. 19. Pt recovering from stroke experiences visual changes 64. a. Obtain BP 41. 8. Cyanosis of the oral cavity and lips a. Stroke occurred at occipital area 65. 20. First thing to conser w/ eye assessment 66. a. Administer O2 67. a. Level of understan 42. 9. Thin watery discharge a. rhinitis 43. 10. Blackish fur coating on the tongue 44. a. Have you taken antibiotics 45. 11. 34 weeks pregnant woman (SELECT ALL APPLY) a. She has been unable to wear contact lenses b. She states that she is experiencing blurry vision c. The client is contemplating that her eyes feel very dry 46. 12. 24 year old pt 47. a. hyperopia 48. 13. Immediate intervention 49. a. Acute glaucoma 50. 14. Sinusitis- 21. For eye patch a.  Assistant with reading 68. 22. where do external eat infections usually occur? a. Otitis external 69. 23. 21. after stroke has a change in vision? a. Occipital region stroke 70. 24. Priority- a. age?, b. verbal communication, c. race, 71. 25. sore throat associated with a. -inner ear infection 72. 26. Macula degeneration- a. loss of central vision 73. 27. Nose bleed- a. check bp 74. 28. 5. Nystagmus- a. jerky movements 75. 76.