• NAGELHOUT
PHARMACOLOGY 09/19/2026
Exam
Test Bank 3 Advanced Health Assessment and
Diagnostic Reasoning 5th Edition Rhoads,
Petersen | All Chapters (1–18) | 2025 Version |
A+ || New Update | | Complete A+
Guide
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right
upper quadrant. Which action should the nurse take next?
P 1
, • NAGELHOUT
PHARMACOLOGY 09/19/2026
Exam
Auscultate over the other 3 abdominal quadrants.
Count the number of bowel sounds per minute.
Note the character and frequency of bowel sounds.
Count to determine how many bowel sounds occur in one minute. - Correct Answer :Note the character and
frequency of bowel sounds.
Rationale
Bowel sounds originate from the air and fluid movement through the stomach and intestines. A wide range of
normal sounds can occur depending on when the last meal was ingested. The nurse should assess for
hyperactive or hypoactive bowel sounds during auscultation, noting the character and frequency. It is not
necessary to count the number of bowel sounds per minute and to listen to all four quadrants. It is necessary to
listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.
During cardiac auscultation, the nurse hears a split in the second heart sound when listening to the second left
intercostal space of a male client. To assess this sound more fully, what action should the nurse implement?
Inch the stethoscope down the left side of the client's sternum.
Ask the client to cough and then listen at the site again.
Instruct client to hold his breath so the sound is clearer.
Listen to the sound while observing the client's respirations. - Correct Answer :Listen to the sound while
observing the client's respirations.
Rationale
A split S2 is heard only in the pulmonic valve area (second left interspace). Listening while observing respirations
allows the examiner to determine the type of S2 split that is occurring. Other actions are not useful in
auscultating a split S2.
The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light
reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a
light toward one eye from the client's side. What would the nurse expect to see at this time?
A consensual response in the opposite eye.
P 2
, • NAGELHOUT
PHARMACOLOGY 09/19/2026
Exam
No change in the eye on the opposite side of the face.
Dilation of the eye on the opposite side of the face.
Dilation of the eye on the same side of the face. - Correct Answer :A consensual response in the opposite eye.
Rationale
To test the pupillary light reflex, the nurse should darken the room and ask the client to gaze into the distance to
dilate the pupils. Then the nurse should advance a bright light into one pupil and note any response. Normally
there will be constriction of the same-sided pupil (a direct light reflex) and simultaneous constriction of the other
pupil (a consensual light reflex). The approximate pupil size that occurs when the light is shined into the eye
should be estimated in millimeters using a gauge located on the penlight or in a healthcare record. The response
to light and pupil size should also be documented.
Which procedure should the nurse use to assess for a pulse deficit?
Compare the brachial pulse and femoral pulse.
Document the observed pulse rate and quality.
Obtain the systolic blood pressure and subtract the apical pulse.
Measure the apical pulse and compare it to the peripheral pulse. - Correct Answer :Measure the apical pulse and
compare it to the peripheral pulse.
Rationale
A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and the radial
pulse palpated at the wrist. The nurse should measure the apical pulse and compare it to the peripheral pulse to
assess for a pulse deficit. If the pulse number is different from the apical pulse, then the radial pulse rate should
be subtracted from the apical pulse and the remaining number is the number that should be recorded for the
pulse deficit.
A Muslim male client refuses to let the female nurse listen to his breath sounds during the examination. How
should the nurse respond?
Explain how the nursing skill will be performed before proceeding.
Examine client with an additional healthcare provider for support.
P 3
, • NAGELHOUT
PHARMACOLOGY 09/19/2026
Exam
Request a male nurse or healthcare provider to perform the exam.
Avoid any skills that involve touching the client during the exam. - Correct Answer :Request a male nurse or
healthcare provider to perform the exam.
Rationale
Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part of their
body to healthcare members. Muslim clients are accustomed to examination by "same-sex" healthcare
providers.
Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound
during auscultation of the heart?
Murmur.
Ejection click.
Friction rub.
Normal heart sound. - Correct Answer :Friction rub.
Rationale
A high-pitched, scratchy, or grating sound heard during auscultation of the heart is called a pericardial friction
rub, which is associated with inflammation of the pericardium, often seen during the following week in a client
after a myocardial infarction. To best hear the pericardial friction rub, the nurse should have the client sitting
upright and leaning forward while the client holds their breath and the nurse listens with the diaphragm of the
stethoscope at the apex and left lower sternal border.
A client reports a recent onset of nausea and vomiting. What subjective information is important for the nurse to
ascertain?
Ask how much weight the client gained on vacation.
Ask whether the client has been in a foreign country recently.
Observe the symmetry of the abdomen.
P 4
PHARMACOLOGY 09/19/2026
Exam
Test Bank 3 Advanced Health Assessment and
Diagnostic Reasoning 5th Edition Rhoads,
Petersen | All Chapters (1–18) | 2025 Version |
A+ || New Update | | Complete A+
Guide
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right
upper quadrant. Which action should the nurse take next?
P 1
, • NAGELHOUT
PHARMACOLOGY 09/19/2026
Exam
Auscultate over the other 3 abdominal quadrants.
Count the number of bowel sounds per minute.
Note the character and frequency of bowel sounds.
Count to determine how many bowel sounds occur in one minute. - Correct Answer :Note the character and
frequency of bowel sounds.
Rationale
Bowel sounds originate from the air and fluid movement through the stomach and intestines. A wide range of
normal sounds can occur depending on when the last meal was ingested. The nurse should assess for
hyperactive or hypoactive bowel sounds during auscultation, noting the character and frequency. It is not
necessary to count the number of bowel sounds per minute and to listen to all four quadrants. It is necessary to
listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.
During cardiac auscultation, the nurse hears a split in the second heart sound when listening to the second left
intercostal space of a male client. To assess this sound more fully, what action should the nurse implement?
Inch the stethoscope down the left side of the client's sternum.
Ask the client to cough and then listen at the site again.
Instruct client to hold his breath so the sound is clearer.
Listen to the sound while observing the client's respirations. - Correct Answer :Listen to the sound while
observing the client's respirations.
Rationale
A split S2 is heard only in the pulmonic valve area (second left interspace). Listening while observing respirations
allows the examiner to determine the type of S2 split that is occurring. Other actions are not useful in
auscultating a split S2.
The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light
reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a
light toward one eye from the client's side. What would the nurse expect to see at this time?
A consensual response in the opposite eye.
P 2
, • NAGELHOUT
PHARMACOLOGY 09/19/2026
Exam
No change in the eye on the opposite side of the face.
Dilation of the eye on the opposite side of the face.
Dilation of the eye on the same side of the face. - Correct Answer :A consensual response in the opposite eye.
Rationale
To test the pupillary light reflex, the nurse should darken the room and ask the client to gaze into the distance to
dilate the pupils. Then the nurse should advance a bright light into one pupil and note any response. Normally
there will be constriction of the same-sided pupil (a direct light reflex) and simultaneous constriction of the other
pupil (a consensual light reflex). The approximate pupil size that occurs when the light is shined into the eye
should be estimated in millimeters using a gauge located on the penlight or in a healthcare record. The response
to light and pupil size should also be documented.
Which procedure should the nurse use to assess for a pulse deficit?
Compare the brachial pulse and femoral pulse.
Document the observed pulse rate and quality.
Obtain the systolic blood pressure and subtract the apical pulse.
Measure the apical pulse and compare it to the peripheral pulse. - Correct Answer :Measure the apical pulse and
compare it to the peripheral pulse.
Rationale
A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and the radial
pulse palpated at the wrist. The nurse should measure the apical pulse and compare it to the peripheral pulse to
assess for a pulse deficit. If the pulse number is different from the apical pulse, then the radial pulse rate should
be subtracted from the apical pulse and the remaining number is the number that should be recorded for the
pulse deficit.
A Muslim male client refuses to let the female nurse listen to his breath sounds during the examination. How
should the nurse respond?
Explain how the nursing skill will be performed before proceeding.
Examine client with an additional healthcare provider for support.
P 3
, • NAGELHOUT
PHARMACOLOGY 09/19/2026
Exam
Request a male nurse or healthcare provider to perform the exam.
Avoid any skills that involve touching the client during the exam. - Correct Answer :Request a male nurse or
healthcare provider to perform the exam.
Rationale
Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part of their
body to healthcare members. Muslim clients are accustomed to examination by "same-sex" healthcare
providers.
Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound
during auscultation of the heart?
Murmur.
Ejection click.
Friction rub.
Normal heart sound. - Correct Answer :Friction rub.
Rationale
A high-pitched, scratchy, or grating sound heard during auscultation of the heart is called a pericardial friction
rub, which is associated with inflammation of the pericardium, often seen during the following week in a client
after a myocardial infarction. To best hear the pericardial friction rub, the nurse should have the client sitting
upright and leaning forward while the client holds their breath and the nurse listens with the diaphragm of the
stethoscope at the apex and left lower sternal border.
A client reports a recent onset of nausea and vomiting. What subjective information is important for the nurse to
ascertain?
Ask how much weight the client gained on vacation.
Ask whether the client has been in a foreign country recently.
Observe the symmetry of the abdomen.
P 4
