NUR 504 EXAM 2 – ADVANCED HEALTH ASSESSMENT –ACTUAL QUESTIONS COMPLETE ANSWERS WITH DETAILED RATIONALES | UNIVERSITY OF ST. THOMAS

NUR 504 EXAM 2 – ADVANCED HEALTH ASSESSMENT –ACTUAL QUESTIONS COMPLETE ANSWERS WITH DETAILED RATIONALES | UNIVERSITY OF ST. THOMAS 1. A 68-year-old male patient reports a sudden onset of severe, tearing chest pain radiating to his back. His blood pressure is 100/70 mmHg in the right arm and 140/90 mmHg in the left arm. What is the priority nursing action? A. Administer sublingual nitroglycerin B. Prepare for immediate echocardiogram C. Administer morphine for pain relief D. Notify the provider of possible aortic dissection Answer: D. Notify the provider of possible aortic dissection Rationale: The presentation of sudden tearing chest pain with a significant blood pressure differential between arms is classic for aortic dissection. Prompt notification and preparation for advanced imaging are critical. Nitroglycerin is contraindicated in right ventricular infarct and not first-line for dissection; morphine may mask symptoms, and echocardiogram is not the definitive emergent test. 2. During a cardiac auscultation, the nurse hears a high-pitched, blowing diastolic murmur at the left sternal border. The patient leans forward, and the murmur becomes louder. This finding is most consistent with which condition? A. Mitral stenosis B. Aortic regurgitation C. Pulmonic stenosis D. Tricuspid regurgitation Answer: B. Aortic regurgitation Rationale: Aortic regurgitation produces a high-pitched, blowing decrescendo diastolic murmur best heard at the left sternal border. Leaning forward and having the patient exhale fully brings the murmur closer to the chest wall, increasing its audibility. Mitral stenosis is a diastolic rumble, and stenotic murmurs are systolic. 3. The nurse is assessing a patient's carotid arteries. Which technique is safest and most appropriate? A. Palpating both carotid arteries simultaneously to compare pulses B. Auscultating for bruits before palpation C. Palpating one carotid artery at a time gently D. Applying firm pressure to assess for occlusion Answer: C. Palpating one carotid artery at a time gently Rationale: Palpating one carotid at a time prevents compromising cerebral blood flow and avoids stimulating the carotid sinus, which could cause bradycardia or syncope. Auscultation for bruits should be performed after palpation to avoid missing a high-grade stenosis that could be completely occluded by palpation pressure. Simultaneous palpation is dangerous. 4. A patient's ECG shows a prolonged PR interval (0.20 seconds). The nurse recognizes this as which type of heart block? A. First-degree AV block B. Second-degree type I (Wenckebach) C. Second-degree type II (Mobitz II) D. Third-degree AV block Answer: A. First-degree AV block Rationale: A prolonged PR interval indicates delayed conduction through the atrioventricular node, characteristic of first-degree AV block. It is often benign but requires monitoring. Second-degree blocks show dropped beats, and third-degree has complete dissociation. 5. A 52-year-old woman presents with dyspnea on exertion and paroxysmal nocturnal dyspnea. On cardiac examination, the nurse notes an S3 gallop and jugular venous distension. These findings are indicative of: A. Left-sided heart failure only B. Right-sided heart failure only C. Pericarditis D. Both left and right-sided heart failure Answer: D. Both left and right-sided heart failure Rationale: The S3 gallop is a hallmark of left ventricular failure and volume overload. Jugular venous distension indicates elevated right heart pressures. The combination of pulmonary symptoms (dyspnea, PND) with systemic venous congestion (JVD) points to biventricular failure. 6. The nurse is assessing the peripheral pulses of an elderly diabetic patient. The dorsalis pedis pulse is not palpable on the right foot. What is the next best step? A. Document the pulse as absent B. Use a Doppler ultrasound device to assess for flow C. Assess the posterior tibial pulse only D. Elevate the foot and reassess Answer: B. Use a Doppler ultrasound device to assess for flow Rationale: In elderly patients, especially those with diabetes, peripheral pulses may be difficult to palpate due to edema or arterial calcification. A Doppler device is a non-invasive, sensitive tool to detect blood flow. Documenting it as absent without further assessment may lead to unnecessary interventions. Elevating the foot would worsen ischemia if present. 7. A patient taking furosemide for heart failure has a serum potassium of 3.1 mEq/L and is also on digoxin. What is the nurse's priority assessment? A. Liver function tests B. Serum sodium level C. Cardiac rhythm monitoring D. Daily weight Answer: C. Cardiac rhythm monitoring Rationale: Hypokalemia (K+ 3.5) potentiates digoxin toxicity, leading to severe dysrhythmias. The priority is continuous cardiac monitoring to detect early arrhythmias. While sodium and weight are important, they are not the immediate life-threatening concern. Liver function is unrelated. 8. During a respiratory assessment, the nurse percusses the posterior chest and notes a dull sound over the right lower lobe. Which condition is most consistent with this finding? A. Pneumothorax B. Emphysema