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NURS 6512 exam 3CA

NURS 6512 exam 3CA • The autonomic nervous system coordinates which of the following? a. High-level cognitive function b. Balance and affect c. Internal organs of the body d. Balance and equilibrium e. Emotions and behavior The autonomic nervous system coordinates the internal organs of the body by the sympathetic and parasympathetic nervous systems. The other options are associated with the cerebral cortex, whose function consists of determining intelligence, personality, and motor function. REF: p. 544 • The major function of the sympathetic nervous system is to a. orchestrate the stress response. b. coordinate fine motor movement. c. determine proprioception. d. contribute input from visual, labyrinthine, and proprioceptive sources. e. perceive stereognosis. Stimulation of the sympathetic branch of the autonomic nervous system prepares the body for emergencies for fight or flight (stress response). The cerebellum plays a key role in the coordination of fine motor movements. Recognition of body parts and awareness of body position (proprioception) are dependent on the parietal lobe. The basal ganglia contribute input from visual, labyrinthine, and proprioceptive sources. Stereognosis is the ability to perceive weight and form of solid objects by touch and is not under sympathetic control. REF: p. 544 • The parasympathetic nervous system maintains the day-to-day function of a. digestion. b. response to stress. c. lymphatic supply to the brain. d. lymphatic drainage of the brain. e. coordinating fine motor movements. The parasympathetic division functions in a complementary and a counterbalancing manner to conserve body resources and maintain day-to-day body functions such as digestion and elimination. REF: p. 544 • Cerebrospinal fluid serves as a a. motor nerve impulse transmitter. b. red blood cell conveyer. c. shock absorber. d. mediator of voluntary skeletal movement. e. sensory nerve impulse transmitter. Cerebrospinal fluid circulates between an interconnecting system of ventricles in the brain and around the brain and spinal cord, serving as a shock absorber. Neurotransmitters are chemicals that transmit nerve impulses from one nerve cell to another. The cerebrospinal fluid does not play a role in red blood cells or in voluntary skeletal movement. REF: p. 545 • The motor cortex of the brain is in the a. corpus callosum. b. frontal lobe. c. limbic system. d. occipital lobe. e. parietal lobe. The frontal lobe contains the motor cortex associated with voluntary skeletal movement and fine repetitive motor movements, as well as the control of eye movements. The corpus callosum interconnects the counterpart areas in each hemisphere, unifying the cerebrum’s higher sensory and motor functions. The limbic system mediates the sense of smell and certain patterns of behavior that determine survival, such as mating, aggression, fear, and affection. The occipital lobe contains the primary vision center and provides interpretation of visual data. The parietal lobe is primarily responsible for processing sensory data as they are received. REF: p. 546 • The thalamus is the major integration center for perception of a. speech. b. olfaction. c. pain. d. thoughts. e. visceral responses to emotions. The thalamus is the major integrating center for perception of various sensations such as pain and temperature, serving as the relay center between the basal ganglia and cerebellum. The reception of speech and interpretation of speech is located in the Wernicke area. The olfactory sense is processed in the parietal lobe. The cerebrum holds memories, allows you to plan, and enables you to imagine and think. The limbic system mediates the sense of smell and certain patterns of behavior (primitive behaviors, visceral response to emotional and biologic rhythms) that determine survival, such as mating, aggression, fear, and affection. REF: p. 546 • The awareness of body position is known as a. extrapyramidal. b. graphesthesia. c. stereognosis. d. two-point discrimination. e. proprioception. Recognition of body parts and awareness of body position is known as proprioception. This is dependent on the parietal lobe. REF: p. 546 • Which area of the brain is responsible for perceiving sounds and for determining their source? a. Frontal lobe b. Occipital lobe c. Parietal lobe d. Temporal lobe e. Brainstem The temporal lobe is responsible for the perception and interpretation of sounds and determination of their source. The frontal lobe contains the motor cortex associated with voluntary skeletal movement. The occipital lobe contains the primary vision center. The parietal lobe is primarily responsible for processing received sensory data. The brainstem is the pathway between the cerebral cortex and the spinal cord, and it controls many involuntary functions. REF: p. 546 • Nerves that arise from the brain rather than the spinal cord are called a. sympathetic. b. parasympathetic. c. cranial. d. autonomic. e. lower motor neurons. ANS: C Cranial nerves are peripheral nerves that arise from the brain rather than the spinal cord. Sympathetic, parasympathetic, and autonomic refer to the autonomic nervous system. Lower motor neurons arise in the spinal cord. REF: p. 547 • If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requires further evaluation? a. CN I, olfactory b. CN V, trigeminal c. CN IX, glossopharyngeal d. CN XI, spinal accessory e. CN XII, hypoglossal CN XI is responsible for the motor ability to shrug the shoulders. CN I is associated with smell reception and interpretation. CN V is associated with opening of the jaw; chewing; and sensation of the cornea, iris, conjunctiva, eyelids, forehead, nose, teeth, tongue, ear, and facial skin. CN IX is associated with swallowing function, sensation of the nasopharynx, gag reflex, taste, secretion of salivary glands, carotid reflex, and swallowing. CN XII is associated with movement of the tongue. REF: p. 553 • The major portion of brain growth and myelinization occurs between ____ year(s) of age. a. birth and 1 b. 2 and 3 c. 4 and 7 d. 11 and 14 e. 16 and 21 The major portion of brain growth occurs in the first year of life along with myelinization of the brain and nervous system. REF: p. 549 • Motor maturation proceeds in an orderly progression from a. peripheral to central. b. head to toe. c. lateral to medial. d. pedal to cephalic. e. toe to head. Motor maturation proceeds in a cephalocaudal direction. Motor control of the head and neck develops first followed by the trunk and extremities. The other choices are incorrect because they relate maturation sequence inappropriately. REF: p. 549 • Normal changes of the aging brain include a. increased velocity of nerve conduction. b. diminished perception of touch. c. increased total number of neurons. d. decreased dermatomes. e. diminished intelligence quotient. Sensory perceptions of touch and pain are diminished by aging. The velocity of nerve impulse conduction declines, so response to stimuli takes longer. The number of cerebral neurons is thought to decrease by 1% a year beginning at 50 years of age; however, the vast number of reserve cells inhibits the appearance of clinical signs. Dermatomal patterns do not change. Acquired knowledge is maintained throughout life. REF: p. 549 • The area of body surface innervated by a particular spinal nerve is called a a. dermatome. b. nerve pathway. c. spinal accessory area. d. cutaneous zone. e. spinal tract. The sensory and motor fibers of each spinal nerve supply and receive information to a segment of skin known as a dermatome. Nerve pathway and spinal accessory area refer to nerve routes; cutaneous zone refers to a skin area that transmits fine mechanical information and normal exogenous thermal information at the same time. Spinal tracts are located in the spinal cord. REF: p. 547 • Environmental hazards and cognitive function are data needed for the personal and social history section of a neurologic assessment for a. adolescents. b. every patient. c. persons with seizures. d. pregnant women. e. infants. Exposure to lead, arsenic, insecticides, organic solvents, dangerous equipment, and work at heights or in water are important factors to consider in the personal and social history of all patients. REF: p. 551 • A neurologic past medical history should include data about a. family patterns of dexterity and dominance. b. circulatory problems. c. educational level. d. immunizations. e. allergies. The neurologic past medical history should include data concerning neurovascular problems such as stroke, aneurysm, and brain surgery. The other answers are not pertinent medical information for the neurologic past medical history. REF: p. 551 • When assessing superficial pain, touch, vibration, and position perceptions, you are testing a. motor function. b. cerebellar function. c. sensory function. d. tendon reflexes. e. emotional status. Superficial pain, touch, vibration, and position perceptions are sensory functions. Cerebellar function and tendon reflexes are neuromuscular functions, and emotional status is regulated in the amygdala within the temporal lobe. REF: p. 561 • You are examining a patient in the emergency department who has recently sustained head trauma. To initially assess this patient’s neurologic status, you would a. ask him to discriminate between the smell of orange and peppermint. b. test the six cardinal points of gaze. c. palpate the jaw muscles as the patient clenches teeth. d. observe for swallowing and test the gag reflex. e. test the patient’s tongue movements. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Testing of the six cardinal points of gaze involves CN VI, which would be a priority. REF: p. 554 • You are initially evaluating the equilibrium of Ms. Q You ask her to stand with her feet together and arms at her sides. She loses her balance. Ms. Q has a positive a. Kernig sign. b. Homan sign. c. McMurray test. d. Romberg sign. e. Murphy sign. The Romberg test has the patient stand with his or her eyes closed, feet together, and arms at the sides. Slight swaying movement of the body is expected but not to the extent of falling. Loss of balance results in a positive Romberg test. Kernig sign tests for meningeal irritation, Homan sign tests for venous thrombosis, and McMurray test is a rotation test for demonstrating a torn meniscus. A positive Murphy sign is usually a sign of gallbladder disease. REF: p. 559 • The finger-to-nose test allows assessment of a. coordination and fine motor function. b. point location. c. sensory function. d. two-point discrimination. e. stereognosis. To perform the finger-to-nose test, the patient closes both eyes, and touches his or her nose with the index finger, alternating hands while gradually increasing the speed. This tests coordination and fine motor skills. All of the other choices test sensory function without motor function. REF: p. 557 • You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the a. back. b. palms. c. fingertips. d. upper arms. e. chest. On the fingertips and toes, two points are commonly felt when 2 to 8 mm apart. A greater distance is expected for discrimination of two points on other body parts, such as the back (40 to 70 mm) or chest and forearms (40 mm). REF: p. 562 • As Mr. B enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B’s pattern as a. dystonic ataxia. b. cerebellar ataxia. c. steppage gait. d. tabetic stamping. e. Parkinsonian gait. A cerebellar gait (cerebellar ataxia) occurs when the patient’s feet are wide based with a staggering gait, lurching from side to side, often accompanied by swaying of the trunk. Dystonic ataxia is jerky dancing movements that appear nondirectional. Steppage gait is noted when the hip and knee are elevated excessively high to lift the plantar flexed foot off the ground. The foot is brought down with a slap, and the patient is unable to walk on the heels. Tabetic stamping occurs when the legs are positioned far apart, lifted high, and forcibly brought down with each step; in this case, the heel stamps on the ground. In Parkinsonian gait, the patient’s posture is stooped, and the body is held rigid; steps are short and shuffling, with hesitation on starting and difficulty stopping. REF: p. 559 • Deep pressure tests are used mostly for patients who are experiencing a. absent superficial pain sensation. b. gait and stepping disturbances. c. lordosis, osteoporosis, or arthritis. d. brisk reflexes. e. tonic neck or torso spasms. Deep pressure sensation is tested by squeezing the trapezius, calf, or biceps muscle, thus causing discomfort. When superficial pain sensation is not intact, then further assessments of temperature and deep pressure sensation are performed. REF: p. 561 • To assess a cremasteric reflex, the examiner strokes the a. skin around the anus and observes for the anal wink. b. abdomen and observes whether the umbilicus moves away from the stimulus. c. inner thigh and observes whether the testicle and scrotum rise on the stroked side. d. palm and observes whether the fingers attempt to grasp. e. sole of the foot and observes whether the toes fan down and out. Stroking the inner thigh of a male patient (proximal to distal) will elicit the cremasteric reflex. The testicle and scrotum rise on the stroked side. Stoking the skin around the anus produces reflexive contracture of the external anal sphincter referred to as the anal wink. Stroking the sole of the foot elicits a Babinski sign, stroking the abdomen elicits an abdominal reflex, and stroking the palm elicits a palmar grasp. REF: p. 562 • You have asked a patient to close his eyes and identify an object placed in his hand. You are evaluating a. stereognosis. b. graphesthesia. c. vibratory sense. d. two-point discrimination. e. extinction phenomenon. Stereognosis is the ability to recognize an object through touch and manipulation. Tactile agnosia, an inability to recognize objects by touch, suggests a parietal lobe lesion. Graphesthesia tests the patient’s ability to identify the figure being drawn on his or her palm. The vibratory sense uses a tuning fork placed on a bony prominence. Two-point discrimination uses two sharp objects to determine the distance at which the patient can no longer distinguish the two points. The extinction phenomenon tests sensation by simultaneously touching bilateral sides of the body with a sterile needle. REF: p. 562 • The ability to recognize a number traced on the skin is called a. stereognosis. b. graphesthesia. c. extinction phenomenon. d. two-point discrimination. e. proprioception. The ability to recognize a number traced on the skin is called graphesthesia. Stereognosis is the ability to recognize an object through touch and manipulation. The extinction phenomenon test and two-point discrimination assess the person’s ability to discern the number of pinpoints and their location. Proprioception is the sensation of position and muscular activity originating from within the body. REF: p. 562 • Which one of the following conditions is consistent with Brown-Séquard syndrome? a. Central sensory loss that is generalized b. Motor paralysis on lesion side of the body c. Multiple peripheral neuropathy of the joints d. Spinal root paralysis below the umbilicus e. Pain and temperature loss on lesion side of body Partial spinal sensory syndrome (Brown-Séquard syndrome) is noted when pain and temperature sensation loss occur one to two dermatomes below the lesion on the opposite side of the body from the lesion. Proprioceptive loss and motor paralysis occur on the lesion side of the body. REF: p. 562 • To assess spinal levels L2, L3, and L4, which deep tendon reflex should be tested? a. Triceps b. Patellar c. Biceps d. Achilles e. Brachioradial To assess spinal levels L2 to L4, the patellar reflex should be tested. The patellar tendon is the only deep tendon that assesses the lumbar spinal level. The triceps, biceps, and brachioradial deep tendon reflexes are tested to assess the cervical spine, and the Achilles tendon is tested to assess the sacral spine. REF: p. 563 • When using a monofilament to assess sensory function, the examiner a. uses two simultaneous monofilaments on similar bilateral points and then compares results. b. applies both a monofilament and a pin on similar bilateral points and then compares results. c. applies pressure to the monofilament until the filament bends. d. strokes the monofilament along the skin from proximal to distal areas. e. assesses only the dorsal surface of the foot with the patient’s eyes open. The monofilament is placed on several smooth spots of the patient’s plantar foot for 1 seconds. Adequate pressure applied by the monofilament is measured by the bend of the monofilament. REF: p. 565 • Visible or palpable extension of the elbow is caused by reflex contraction of which muscle? a. Serratus anterior b. Biceps c. Pectoralis major d. Triceps e. Deltoid The triceps tendon, when directly hit with the reflex hammer just above the elbow, will cause contraction of the triceps muscle and extension of the elbow. REF: p. 564 • It is especially important to test for ankle clonus if a. deep tendon reflexes are hyperactive. b. the patient has a positive Kernig sign. c. the Romberg sign is positive. d. the patient has peripheral neuropathy. e. deep tendon reflexes are hypoactive. Test the ankle clonus when reflexes are hyperactive. Support the patient’s knee in a flexed position and briskly dorsiflex the foot with your other hand. If clonus is present, there is recurrent ankle plantar flexion movement as long as the examiner retains the foot in dorsiflexion. Sustained clonus signifies the hypertonia of an upper motor neuron lesion. REF: p. 565 • Which sign is associated with meningitis and intracranial hemorrhage? a. Babinski sign b. Asymmetric tonic neck reflex c. Doll’s eye movement d. Nuchal rigidity e. Moro reflex A stiff neck or nuchal rigidity is a sign associated with meningitis and intracranial hemorrhage. Test this by lifting the head of the patient to touch the chin while the patient lies in a supine position. Pain and resistance to neck motion are associated with nuchal rigidity. All of the other options are expected findings in infants and are not related to meningitis in adults. REF: p. 565 • When assessing a 17-year-old patient for nuchal rigidity, you gently raise his head off the examination table. He involuntarily flexes his hips and knees. To confirm your suspicions associated with this positive test result, you would also perform a test for the _____ sign. a. Kernig b. Babinski c. obturator d. Brudzinski e. Murphy The first action elicited the Brudzinski sign. This sign is an indicator of meningeal irritation. To confirm meningeal irritation, you would test for the Kerning sign, also a meningeal sign. REF: p. 566 • On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? a. 0 b. 1 c. 2 d. 3 e. 4 0 indicates absent reflexes; 1 indicates sluggish or diminished reflex; 2 indicates active or expected response; 3 indicates more brisk than expected, slightly hyperactive; and 4 indicates brisk, hyperactive, with intermittent or transient clonus. REF: p. 564 • Cranial nerve XII may be assessed in an infant by a. watching the infant’s facial expressions when crying. b. observing the infant suck and swallow. c. clapping hands and watching the infant blink. d. observing the infant’s rooting reflex. e. checking the infant’s gag reflex. Cranial nerve (CN) XII may be assessed in an infant by observing the infant suck and swallow and by pinching the nose and then observing for the mouth to open and the tip of the tongue to rise in a midline position. Watching the infant’s facial expressions when crying assesses CN VII, clapping hands and watching the infant blink tests CN VIII, and observing the rooting reflex assesses CN V. A gag reflex assesses CN IX and X. REF: p. 567 • At what age should an infant begin to transfer objects from hand to hand? a. 2 months b. 4 months c. 7 months d. 10 months e. 12 months Transferring objects hand to hand begins at 7 months. Purposeful release of objects is noted as a normal finding by 10 months. Purposeful movements, such as reaching and grasping for objects, begin at about 2 months of age. The progress of taking objects with one hand begins at 6 months. There should be no tremors or constant overshooting of movements. REF: p. 566 • A positive Babinski sign is normal until what age? a. 3 to 6 months b. 9 to 15 months c. 16 to 24 months d. 3 years e. 5 years A positive Babinski sign, fanning of the toes and dorsiflexion of the great toe, is a normal finding until the infant is 16 to 24 months old. REF: p. 568 • Which of the following is a concern, rather than an expected finding, in older adults? a. Reduced ability to differentiate colors b. Bilateral pillrolling of the fingers c. Absent plantar reflex d. Diminished senses of smell and taste e. Reduced gag reflex Bilateral pillrolling is indicative of Parkinson disease; the other choices are expected findings with aging. REF: p. 579 • Ipsilateral Horner syndrome indicates a cerebrovascular accident (CVA) occurring in the a. anterior spinal artery. b. internal or middle cerebral artery. c. posterior inferior cerebellar artery. d. vertebral or basilar arteries. e. anterior portion of the pons. The posterior inferior cerebellar artery supplies the lateral and posterior portion of the medulla. A CVA involving this artery can produce a neurologic sign of ipsilateral Horner syndrome in the eye. REF: p. 576 • An acute polyneuropathy that commonly follows a nonspecific infection occurring 10 to 14 days earlier and that primarily affects the motor and autonomic peripheral nerves in an ascending pattern is a. cerebral palsy. b. HIV encephalopathy. c. Guillain-Barré syndrome. d. Rett syndrome. e. myasthenia gravis. Guillain-Barré syndrome (acute idiopathic polyneuritis) is an acute polyradiculoneuropathy that commonly follows a nonspecific infection that occurred 10 to 14 days earlier. It is characterized by ascending symmetrical weakness with sensation preserved. An increase in the severity occurs over days or weeks. A decrease or absent strength and sensory loss may result along with motor paralysis and respiratory muscle failure. REF: p. 577 • The immune system attacks the synaptic junction between the nerve and muscle fibers blocking acetylcholine receptor sites in a. myasthenia gravis. b. encephalitis. c. multiple sclerosis. d. cerebral palsy. e. trigeminal neuralgia. Myasthenia gravis is a chronic autoimmune neuromuscular disease involving the lower motor neurons and muscle fibers. The immune system of infected individuals produces antibodies that destroy acetylcholine receptor sites at the neuromuscular junction. This blocks the nerve impulse from reaching the muscle and produces muscle fatigue. REF: p. 576 • Diabetic peripheral neuropathy will likely produce a. hyperactive ankle reflexes. b. diminished pain sensation. c. exaggerated vibratory sense. d. hypersensitive temperature perception. e. exaggerated sharp touch sensation. Peripheral neuropathy is a disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves, more commonly in the hands and feet. Patients may have sensation of numbness, tingling, burning, and cramping. In moderate to severe diabetic neuropathy, the patient has wasting of the foot muscles, absent ankle and knee reflexes, decreased or no vibratory sensation below the knees, or loss of pain or sharp touch sensation to the mid-calf level. REF: p. 578 • Persons with Parkinson disease have an altered gait that is characterized by a. short shuffling steps. b. the trunk in a backward position. c. exaggerated swinging of the arms. d. lifting the legs in a high-step fashion. e. wide-based, staggering, and lurching steps. The altered gait of Parkinson disease has short shuffling steps, the posture is stooped forward, and the arms have limited swing. REF: p. 579 • A clinical syndrome of intracranial hypertension that mimics brain tumors is a. meningitis. b. myasthenia gravis. c. Guillain-Barré syndrome. d. pseudotumor cerebri. e. Bell palsy. Pseudotumor cerebri is a clinical syndrome of intracranial hypertension that mimics brain tumors. Its cause is unknown, but one theory is that an impaired venous outflow leads to increased cerebral blood volume; it may also be idiopathic. REF: p. 574 • When auscultating the apex of the lung, you should listen a. even with the second rib. b. 4 cm above the first rib. c. higher on the right side. d. on the convex diaphragm surface. e. directly over the clavicles. The apices of the lungs are 4 cm above the first rib. REF: p. 262 • You are documenting a rash between the eighth and ninth ribs on the lateral border. This intercostal space will be documented in terms of the a. rib immediately above it. b. rib immediately below it. c. number of centimeters it is positioned below the clavicle. d. number of inches it is positioned below the clavicle. e. relationship to the sternum. The number of each intercostal space corresponds to that of the rib immediately above it. REF: p. 263 • To begin counting the ribs and the intercostal spaces, you begin by palpating the reference point of the a. distal point of the xiphoid. b. manubriosternal junction. c. suprasternal notch. d. acromion process. e. clavicle. The angle of Louis, the junction of the manubrium and the sternum, corresponds to the second rib, the reference point for counting ribs and intercostal spaces. REF: p. 263 • Fetal gas exchange is mediated by the a. pleura. b. heart. c. amniotic fluid. d. placenta. e. lungs. The placenta is the source for fetal gas exchange; the lungs contain no air, and the alveoli are collapsed. REF: p. 264 • The foramen ovale should close by a. 24 weeks of gestation. b. the initiation of labor. c. within minutes of birth. d. 4 weeks of age. e. 12 months of age. The decrease in pulmonary pressures within the first minutes of life leads to closure of the foramen ovale. REF: p. 264 • Increased oxygen tension in the arterial blood of a newborn infant causes a. closure of the ductus arteriosus. b. hyperinflation of the lungs. c. passive respiratory movements. d. reopening of the foramen ovale. e. the pulmonary arteries to contract. Increased oxygen tension in the arterial blood usually stimulates contraction and closure of the ductus arteriosus. REF: p. 264 • The anteroposterior diameter of the chest is normally approximately the same as the transverse diameter in which age group? a. Infants b. School-age children c. Adolescents d. Young adults e. Older adults The chests of infants are generally round, with equal dimensions of anteroposterior and transverse diameters. REF: p. 264 • To accommodate the enlarging uterus of pregnancy, the chest changes result in a. intercostal muscle atrophy. b. lowering of the resting diaphragm. c. decreased alveoli expansion. d. decreased diaphragmatic movement. e. increased costal angle. The costal angle progressively increases from approximately 68.5 degrees to 103.5 degrees in later pregnancy. The resting diaphragm rises, yet diaphragmatic movement increases, the alveolar ventilation and tidal volume increase, and the muscles do not atrophy. REF: p. 265 • The characteristic barrel chest of an older adult is caused by a combination of factors, including a. skeletal changes of aging. b. increased muscular expansion of the chest wall. c. less fibrous alveoli. d. increased vital capacity. e. increased lung resiliency. Skeletal changes associated with aging include an emphasis of the dorsal curve of the thoracic spine that contributes to a barrel chest. REF: p. 265 • Nancy is a 16-year-old young woman who presents to the clinic with complaints of severe, acute chest pain. Her mother reports that Nancy, apart from occasional colds, is not prone to respiratory problems. What potential risk factor is most important to assess concerning Nancy’s present problem? a. Anorexia symptoms b. Illegal drug use c. Last menses d. Signs of rheumatic fever e. Sexual activity Illegal drug use, particularly of cocaine, is especially important to prioritize as a social history question for all adolescents and adults who complain of severe chest pain. Cocaine use can lead to tachycardia, hypertension, coronary arterial spasm with infarction, and pneumothorax. REF: p. 267 • A patient describes shortness of breath that gets worse when he sits up. Which term documents this? a. Platypnea b. Orthopnea c. Tachypnea d. Bradypnea e. Hypopnea Dyspnea that increases in the upright posture is called platypnea. Orthopnea is dyspnea that worsens with lying down, tachypnea is increased respiratory rate, and bradypnea is decreased respiratory rate. Hypopnea refers to abnormally shallow respirations. REF: p. 266 • Bradypnea may accompany a. pneumothorax. b. an excellent level of cardiovascular fitness. c. ascites. d. a pulmonary embolus. e. anxiety. Bradypnea, a rate slower than 12 breaths/min, may result from cardiorespiratory fitness. The other choices accompany tachypnea. REF: p. 270 • A 34-year-old man is being seen for complaints of dull pain between the shoulder blades that is more intense with deep breathing and coughing. Upon auscultation of the chest, you suspect that you will hear a. rhonchi. b. expiratory wheeze. c. crackles. d. pleural friction rub. e. crepitus. This patient is describing the bronchi as the source of the pain; the trachea divides at T4–5, between the shoulder blades. The adventitious bronchial sound expected is rhonchi. Wheezing might be expected if the patient had productive coughing or dyspnea; a pleural friction rub usually causes sudden stabbing pain over the pleuritic site. Crepitus can be both palpated and heard; it indicates air in the subcutaneous tissue and is usually found anteriorly and toward the axilla. REF: p. 279 • The most appropriate lighting source to highlight chest movement is (are) a. bright tangential lighting. b. daylight from a window. c. flashlight in a dark room. d. fluorescent ceiling lights. e. a Wood’s lamp. Bright tangential light is best to visualize chest movements. REF: p. 268 • Both pleural effusion and lobar pneumonia are characterized by _____ percussion. a. tympany heard with b. dullness heard on c. resonance heard on d. hyperresonance heard on e. occasional hyperresonance heard on Pleural effusion and lobar pneumonia are more dense than air, with an expected finding of dullness to percussion. Tympany is expected over hollow organs such as the stomach; resonance and hyperresonance are heard over air-filled areas. REF: p. 274 • Which finding suggests a minor structural variation? a. Barrel chest b. Clubbed fingers c. Pectus carinatum d. Retractions e. Tachypnea Barrel chest, clubbed fingers, chest wall retractions, and tachypnea result from compromised respirations; pectus carinatum (pigeon chest) is a minor structural variation. REF: p. 268 • Ms. R, age 74 years, has no known health problems or diseases. You are doing a preventive health care history and examination. Which symptom is associated with an intrathoracic infection? a. Barrel chest b. Cor pulmonale c. Pectus excavatum d. Pectus carinatum e. Malodorous breath Intrathoracic infections may make the breath malodorous; the other conditions will not. REF: p. 273 • In barrel chest, the ratio of the anteroposterior diameter to the transverse (lateral) diameter is a. 0.7 to 0.75. b. 1.0. c. 1.3 to 1.5. d. 1.5 to 2. e. greater than 2. In a barrel chest, an increase in the chest anteroposterior diameter leads to an increase in the thoracic ratio (anteroposterior to transverse diameters) of 1.0, in which the chest is equally wide as it is thick. REF: p. 265 • The patient that you are examining is complaining of pain near the spine. While palpating the spinous process at T7 and medially to the inferior border of the right scapula, the patient feels more intense pain. When viewing the chest radiograph, you will carefully look at which rib? a. Right sixth rib b. Right seventh rib c. Right eighth rib d. Left seventh rib e. Left eighth rib Although each rib articulates with the corresponding vertebra, the palpated spinous process dips down so that the rib you feel in apparent association with the spinous process is actually the number of that process plus 1. REF: p. 263 • The best time to observe and count respirations is a. while the patient is answering questions. b. while weighing the patient. c. after palpating the pulse. d. when the patient is sleeping. e. after a short walk. Respiratory patterns change as the patient speaks and sleeps. Attempting to count during weighing would make the patient self-conscious and affect the respiratory rate. Counting respirations after you palpate the pulse does not make the patient self-conscious because the patient expects you to be counting the pulse. REF: p. 270 • As you take vital signs on Mr. B, age 78 years, you note that his respirations are 40 breaths/min. He has been resting, and his mucosa is pink. Concerning Mr. B’s respirations, you would a. document his rate as normal. b. do nothing because his color is pink. c. note that his rate is below normal. d. report that he has an above-average rate. e. ignore one abnormal result. The normal adult respiratory rate is 12 to 20 breaths/min, with a ratio of respirations to heartbeats of 1:4. Always note any variations in respiratory rate. REF: p. 270 • In which patient situation would you expect to assess tachypnea? a. Patient with depression b. Patient who abuses narcotics c. Patient with metabolic acidosis d. Patient with myasthenia gravis e. Patient with metabolic alkalosis In metabolic acidosis, the body compensates by increasing the respiratory rate to blow off the excess carbon dioxide. The other choices cause respiratory depression. REF: p. 270 • What term would you use to document a respiratory rate greater than 20 breaths/min in an adult? a. Dyspnea b. Orthopnea c. Platypnea d. Tachypnea e. Cheyne-Stokes ANS: D Tachypnea is the correct term for respirations greater than 20 breaths/min. Dyspnea, orthopnea, and platypnea are terms that describe respiratory effort, not rate. Cheyne-Stokes refers to a particular abnormal pattern of respiration. REF: p. 270 • Respiratory effort usually exhibited by the patient with cerebral brain damage is called a. Cheyne-Stokes respiration. b. paroxysmal nocturnal dyspnea. c. Kussmaul breathing. d. Biot respiration. e. ataxic respiration. Cheyne-Stokes respirations occur in children and older adults during sleep but otherwise occur in seriously ill patients, particularly those with brain damage at the cerebral level. The other choices are not apnea associated with cerebral damage. REF: p. 271 • Which site of chest wall retractions indicates a more severe obstruction in a patient with asthma? a. Lower chest b. Along the anterior axillary line c. Above the clavicles d. At the nipple line e. Along the posterior axillary line Asthma more commonly produces retractions of the lower chest. The more severe the obstruction, the greater is the negative pressure produced in the chest during inspiration and retractions are seen in the upper thorax. REF: p. 282 • Which type of apnea requires immediate action? a. Primary apnea b. Secondary apnea c. Sleep apnea d. Periodic apnea of the newborn e. Apnea of prematurity Primary apnea is self-limiting, sleep apnea should be evaluated but does not require immediate action, and periodic apnea of the newborn is a normal condition. Apnea of prematurity is a more intense version of periodic apnea of the newborn. Secondary apnea is grave, and unless resuscitative measures are immediately instituted, breathing will not resume spontaneously. REF: p. 271 • Laryngeal obstructions would elicit which breath sound? a. Fremitus b. Stridor c. Rhonchi d. Crepitus e. Wheezing Obstructions high in the respiratory tree are characterized by stridor. REF: p. 272 • Mr. L has cyanotic lips and nail beds. His lips are pursed, and he has nasal flaring. You suspect that he has cardiac or pulmonary difficulty. What additional sign would correspond with your impression? a. Callus formation on the heels b. Clubbing of the fingers c. Graying of the hair d. Swollen toes and ankles e. Positioning of the head Clubbing of the fingers suggests chronic pulmonary or cardiac difficulty. The other choices do not. REF: p. 273 • Breath odors may alert the examiner to certain underlying metabolic conditions. The odor of ammonia on the breath may signify a. uremia. b. tuberculosis. c. hepatic dysfunction. d. diabetic ketoacidosis. e. intestinal obstruction. The breath smell described as ammonia-like suggests uremia, a renal condition; cinnamon suggests tuberculosis, a musty fish or clover odor suggests hepatic failure, a sweet and fruity odor suggests diabetic ketoacidosis; and a foul or feculent odor suggests intestinal obstruction. REF: p. 277 • An expected finding from chest palpation in the adult would be a. costal angle of 120 degrees. b. cracking over the sternal notch. c. greater right chest expansion. d. crepitus. e. inflexibility of the xiphoid. The sternum and xiphoid in adults are relatively inflexible, without cracking; the expected normal costal angle is 90 degrees, and the chest moves symmetrically. Crepitus is always an abnormal finding. REF: p. 273 • You would expect to document the presence of a pleural friction rub for a patient being treated for a. bronchitis. b. atelectasis. c. pleurisy. d. emphysema. e. pneumonia. A pleural friction rub is caused by inflammation of the pleural surfaces and is expected to be auscultated with pleurisy. REF: p. 280 • Tactile fremitus is best felt a. along the costal margin and xiphoid process. b. in the suprasternal notch along the clavicle. c. at the level of bifurcation of the bronchi. d. posterolaterally over the scapulas. e. in the midaxillary lines. Fremitus is best felt posteriorly and laterally at the level of the bifurcation of the bronchi. There is great variability depending on the intensity and pitch of the voice and the structure and thickness of the chest wall. In addition, the scapulae obscure fremitus. REF: p. 273 • In the most effective percussion technique of the posterior lung fields, the patient cooperates by a. folding the arms in front. b. bending the head back. c. standing and bending forward. d. lying on the side and extending the top arm. e. lying prone. Asking the patient to sit with the head forward and arms folded in front moves the scapula laterally, exposing more lung to percussion. REF: p. 274 • The examiner percusses for diaphragmatic excursion along the a. vertebral column. b. midvertebral line. c. midaxillary line. d. scapular line. e. sternum. The technique for diaphragmatic excursion is to percuss along the scapular line, after the patient inhales deeply, and to mark the site when resonance changes to dullness, representing the diaphragm. The sequence is repeated with exhalation. REF: p. 276 • The diaphragm of the stethoscope is better than the bell for auscultation of the lungs because it a. amplifies all types of sounds. b. filters extraneous sounds. c. pinpoints focal sound areas. d. transmits high-pitched sounds. e. transmits low-pitched sounds. Unless specially modified, the stethoscope does not amplify sound, nor does it filter sound or pinpoint focal sounds. The stethoscope does transmit sound waves from the source to the ear. The diaphragm is the better source because it transmits the normally high-pitched sounds of the lung and has a broader area from which to listen. REF: p. 277 • Breath sounds normally auscultated over most of the lung fields are called a. vesicular. b. hyperresonance. c. bronchial. d. tubular. e. bronchovesicular. The low-intensity sounds heard over most healthy lung tissue are called vesicular breath sounds. REF: p. 277 • Breath sounds normally heard over the trachea are called a. bronchovesicular. b. amphoric. c. crepitus. d. vesicular. e. bronchial. The highest sounds in intensity and pitch are called the bronchial sounds, which are normally heard over the trachea. REF: p. 278 • When there is consolidation in the lung tissue, the breath sounds are louder and easier to hear, whereas healthy lung tissue produces softer sounds. This is because a. consolidation will echo in the chest. b. consolidation is a poor conductor of sound. c. air-filled lung sounds are from smaller spaces. d. air-filled lung tissue is an insulator of sound. e. consolidation causes hyperinflation of the lungs. Whereas air is a poor conductor of sound, more dense consolidation promotes louder sounds and is a better conductor of sound. REF: p. 278 • The middle lobe of the right lung is best auscultated over the a. anterior chest. b. posterior chest. c. axilla. d. midclavicular line. e. scapula. The sounds of the middle lobe of the right lung are best heard in the right axilla. REF: p. 262 • Your older clinic patient is being seen today as a follow-up for a 2-day history of pneumonia. The patient continues to have a productive cough, shortness of breath, and lethargy and has been spending most of the day lying in bed. You should begin the chest examination by a. percussing all lung fields. b. auscultating the lung bases. c. determining tactile fremitus. d. estimating diaphragmatic excursion. e. auscultating the apices. Because the patient has consolidation and has been recumbent and fatigued, the most appropriate first step is to listen to the lung bases before the patient gets exhausted. The lung bases would be the most likely sites for adventitious sounds. REF: p. 277 • Your trauma patient has no auscultated breath sounds in the right lung field. You can hear adequate sounds in the left side. A likely cause of this abnormality could be that the patient a. has a closed head injury. b. has minimal fluid in the pleural space. c. is moaning and in severe pain. d. is receiving high oxygen flow. e. has a pneumothorax. Trauma to the chest can cause an exudative pleural effusion or pneumothorax. In the affected areas, the breath sounds are diminished to absent. REF: p. 285 • Adventitious breath sounds previously referred to as rales has been replaced with the term a. wheezes. b. crunches. c. vesicular. d. crackles. e. rhonchi. ANS: D The term rales has been replaced with the term crackles to describe the sound more precisely. REF: p. 279 • To distinguish crackles from rhonchi, you should auscultate the lungs a. before and after the patient coughs. b. first at the lung base and then at the apex. c. with the patient inhaling and then exhaling. d. with the patient prone and then supine. e. with the patient recumbent and then sitting. To distinguish between crackles and rhonchi, ask the patient to cough and auscultate again over the same area. Rhonchi, because they represent secretions in larger airways, can clear with coughing. REF: p. 279 • A musical squeaking noise heard on auscultation of the lungs is called a. stridor. b. rales. c. rhonchi. d. wheezing. e. friction rub. Wheezes are continuous, high-pitched musical sounds that can be heard on inspiration and expiration. REF: p. 280 • To distinguish between a respiratory friction rub and a cardiac friction rub, ask the patient to a. hold his or her breath. b. lean forward. c. say “99” while you palpate the anterior chest. d. identify the location of his or her pain. e. arch backward. ANS: A A respiratory friction rub results from inflamed pleura rubbing against each other during the respiratory cycle, so if the breath is held, the rub stops. REF: p. 280 • In what position can the mediastinal crunch (Hamman sign) be heard best? a. In a supine position b. Lying on the left side c. Sitting completely upright d. With the head elevated 30 degrees e. In a prone position The Hamman sign is heard with mediastinal emphysema. The adventitious breath sounds are synchronous with the heartbeat and are heard best when the patient leans to the left or lies down on the left side—these maneuvers bring the heart muscle closer to the chest wall. REF: p. 280 • Changes in clarity and volume of spoken sounds during auscultation of the lungs can help you distinguish a. crepitus from stridor. b. a foreign body from a purulent exudate. c. pulmonary edema from pleurisy. d. a right from left tracheal deviation. e. consolidation from airway constriction. When chest auscultation results in decreased breath sounds or wheezes, the examiner can use techniques that involve the spoken word to distinguish these adventitious breath sounds as a result of consolidation rather than narrowing of a patent lumen. REF: p. 280 • During chest assessment, you note the patient’s voice quality while auscultating the lung fields. The voice sound is intensified, there is a nasal quality to the voice, and the e’s sound like a’s. This is indicative of a. lung consolidation. b. emphysema. c. bronchial obstruction. d. pneumothorax. e. asthma. Vocal resonance, as described, indicates lung consolidation. Sounds are transmitted more clearly through consolidation rather than air. Conditions of air trapping such as emphysema and asthma would not produce vocal resonance sounds; bronchial obstruction would more likely result in a wheeze. Pneumothorax would result in diminished or no breath sounds. REF: p. 280 • During chest assessment, you note the patient’s voice quality while you are auscultating the lung fields. The voice sound is intensified, there is a nasal quality to the voice, and e’s sound like a’s. This sound described is called a. sonorous. b. bronchophony. c. pectoriloquy. d. egophony. e. resonance. When the intensity of the spoken voice is increased, there is a nasal quality in which the e’s become stuffy broad a’s. This technique is called egophony. REF: p. 280 • How is the sputum of a viral infection different from the sputum of a bacterial infection? a. There is more sputum production with viral conditions than bacterial infections. b. The sputum is odorous with viral conditions and nonodorous with bacterial infections. c. The sputum is yellow, green, or rust colored with bacterial infections and mucoid with viral. d. The sputum is much thinner with bacterial infections and viscid with viral. e. Viral pneumonia sputum is never blood streaked. The more likely differentiating characteristic between viral and bacterial sputum is the color. Whereas viral infections typically produce mucoid sputum, bacterial infections produce yellow, green, or rust-colored sputum. REF: p. 266 • The respiratory rate of a newborn infant is expected to range from _____ breaths/min. a. 10 to 20 b. 20 to 30 c. 40 to 60 d. 30 to 80 e. greater than 80 The expected rate varies from 40 to 60 respirations per minute, although a rate of 80 is not uncommon REF: p. 281 • A signal for alarm during newborn chest assessment is a. crackles. b. rhonchi. c. gurgles from the gastrointestinal tract. d. stridor. e. a mobile xiphoid. Crackles and rhonchi at birth are caused by the presence of remaining fetal fluid; intermittent gurgles are transmitted bowel sound through the thin-walled chest and are not alarming; stridor is alarming at any age. The newborn’s xiphoid process is more mobile and prominent than in older children. REF: p. 281 • Bronchovesicular breath sounds in young children that are loud and harsh are an indication of a. an accumulation of fluid. b. malignant tumors or solid masses. c. normal, thin chest wall structures. d. pus-filled abscesses and tumors. e. tension pneumothorax. Young children’s chest walls are usually thin and therefore able to normally transmit loud, harsh, and more bronchial breath sounds than can adults. REF: p. 282 • The pregnant woman is expected to develop a. tachypnea and decreased tidal volume. b. deep breathing but not more frequent breathing. c. dyspnea and increased functional residual capacity. d. bradypnea and increased tidal volume. e. tachypnea and increased functional residual capacity. In pregnant women, tidal volume and vital capacity increase, and functional residual capacity decreases. Also, pregnant women breathe more deeply but not more frequently. REF: p. 282 • Expected respiratory changes of normal aging include a. increased chest expansion. b. more frequent use of respiratory muscles. c. accentuated lumbar curve. d. more prominent bony structures. e. flattening of the dorsal thoracic curve. In older adults, chest expansion is decreased, and there is less use of respiratory muscles because of muscle weakness. The dorsal curve of the thoracic spine is prominent with flattening of the lumbar curve with bony landmarks becoming more prominent because of loss of subcutaneous tissue. REF: p. 282 • Dullness to percussion in intercostal spaces is most consistent with the presence of a. asthma. b. empyema. c. pneumonia. d. sickle cell disease. e. pneumothorax. The expected percussion tone over normal lung tissue, accessible in the intercostal spaces, is resonance. Dullness would indicate an area of consolidation, as is seen with pneumonia. REF: p. 274 • Which condition requires immediate emergency intervention? a. Patient with pleuritic pain without dyspnea b. Patient with fever and a productive cough c. Patient with tachypnea but no chest retractions d. Patient with pleuritic pain and rib tenderness e. Patient with absent breath sounds and dull percussion tones A patient who experiences unexpected pleuritic pain without prior respiratory distress or dyspnea has most likely developed a pulmonary embolism, a condition with a high mortality rate. REF: p. 290 • A 29-year-old patient presents with a new complaint of productive cough with purulent sputum. He also complains of right lower quadrant abdominal pain. You suspect pneumonia in the _____ lobe. a. right lower b. right middle c. right upper d. left upper e. left lower Right lower lobe pneumonia can stimulate the tenth and eleventh thoracic nerves, causing right lower quadrant pain, and simulate an abdominal process. REF: p. 288 • Epiglottitis has frequently associated with infection by which organism? a. Respiratory syncytial virus b. Haemophilus influenzae type B c. Adenovirus d. Parainfluenza virus e. Human metapneumovirus Epiglottitis is an acute inflammation of the epiglottis caused by bacterial invasion. Immunization against the bacterium Haemophilus influenzae type B has greatly reduced the incidence in the United States. All of the other choices are viruses associated with bronchiolitis. REF: p. 291

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