Arkansas State University | NURS 6023 NURS6023 Exam 2 advanced assessment Study Guide 2025/2026

Arkansas State University | NURS 6023 NURS6023 Exam 2 advanced assessment Study Guide 2025/2026 Exam 2 Study Guide Lungs and Thorax 1. A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medication. She has had no surgeries. Her mother has allergies and eczema, and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. a. Which disorder of the thorax or lung does this best describe? Asthma 2. A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middle- aged woman appearing her stated age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement, and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. a. What disorder of the thorax or lung best describes her symptoms? Pneumonia 3. A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having rightsided chest pain and severe shortness of breath. He denies any recenttraumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. a. What disorder of the thorax or lung best describes his symptoms? Spontaneous Pneumothorax 4. A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. a. What thorax or lung disorder is most likely causing his symptoms? COPD 5. A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain doesnot radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall. a. What disorder of the chest best describes this disorder? Pericarditis 6. A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left- sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthyappearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. a. Which disorder of the chest best describes these symptoms? Angina Pectoris 7. A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is “ripping out her heart.” It began lessthan an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital's ER for further evaluation. a. What disorder of the chest best describes her symptoms? Dissecting Aortic Aneurysm 8. A 25-year-old accountant presents to your clinic, complaining of intermittent lower right- sided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some Tylenol and put a heating pad on his side but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married, and his wife has a baby due in 2 months. He denies any smoking or illegal drug use. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender. a. What disorder of the chest best describes his symptoms?Pleural Pain 9. A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can't do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination she is in no acute distress. Her blood pressure is 160/100 and her pulse is 100. She is afebrile and her respiratory rate is 16. With auscultation she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examinations the S1 and S2 are distant and an S3 is heard over the apex. a. What disorder of the chest best describes her symptoms? Left- Sided Heart Failure 10. A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite a while. He states he has no symptoms from it and he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest, you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable. a. What disorder of the thorax best describes your findings? Funnel Chest (Pectus Excavatum) 11. Which of the following anatomic landmark associations is correct? a. 2nd intercostal space for needle insertion in tension pneumothorax12. A 55–year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. a. Which of the following diagnoses should you consider because of her gesture? Angina Pectoris 13. A 62-year-old smoker complains of “coughing up small amounts of blood,” so you consider hemoptysis. a. Which of the following should you also consider? Epistaxis 14. Which of the following occurs in respiratory distress? a. Skin between the ribs moves inward with inspiration 15. Which of the following is consistent with good percussion technique? a. Strike the pleximeter over the distal interphalangeal joint. 16. Which of the following percussion notes would you obtain over the gastric bubble? a. Tympany 17. Which of the following conditions would produce a hyperresonant percussion note? a. Large Pneumothorax 18. Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration? a. Bronchial 19. A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. a. What is the most likely explanation for these? Heart Failure 20. When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology? a. Bronchitis 21. A patient with long standing COPD was told by another practitioner that his liver was enlarged and this needed to be assessed. a. Which of the following would be reasonable to do next? Measure the span of the liver 22. You are at your family reunion playing football when your uncle takes a hit to his right lateral thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote area.a. What would your next step be? Press on his sternum and spine simultaneously 23. Which of these statements is true regarding the vertebra prominens? a. The vertebra prominens is: The spinous process of C7. 24. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. a. This characteristic is: A normal finding in a healthy adult 25. When assessing a patients lungs, the nurse recalls that the left lung: a. Consist of two lobes 26. Which statement about the apices of the lungs is true? a. The apices of the lungs: Extend 3 to 4 cm above the inner third of the clavicles 27. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: a. Sternal angle 28. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: a. Muffled voice sounds and symmetric tactile fremitus 29. The primary muscles of respiration include the: a. Diaphragm and intercostals. 30. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. a. The nurse should: Consider this finding as normal for a child this age, and proceed with the examination. 31. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Bilaterally percuss the thorax, noting any differences in percussion tones. 32. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate? a. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea33. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae 34. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. a. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? Tactile fremitus: Is caused by sounds generated from the larynx. 35. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from a. Increased density of lung tissue 36. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. a. Side-to-side 37. When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. a. The nurse interprets that these sounds are Vesicular breath sounds and normal in that location. 38. The nurse is auscultating the chest in an adult. a. Which technique is correct? Firmly holding the diaphragm of the stethoscope against the chest 39. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: a. Dullness 40. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When the bronchial tree is obstructed 41. The nurse knows that a normal finding when assessing the respiratory system of an older adult is: a. Decreased mobility of the thorax 42. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. a. The nurses next action should be toRecognize that these are serious signs, and contact the physician 43. When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? a. Presence of bronchovesicular breath sounds in the peripheral lung fields 44. When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Shape and configuration of the chest wall 45. The nurse knows that auscultation of fine crackles would most likely be noticed in a. The immediate newborn period. 46. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. When part of the lung is obstructed or collapsed 47. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. a. The nurse should assess for signs of which condition? Pulmonary consolidation 48. The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? a. Bronchovesicular breath sounds are: Expected near the major airways 49. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezing 50. A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? a. Anteroposterior-to-transverse diameter ratio of 1:1 51. A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. a. The nurse interprets that these assessment findings are consistent with Pneumothorax52. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. a. The nurse interprets that these assessment findings are consistent with Asthma 53. The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? a. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil. 54. A woman in her 26th week of pregnancy states that she is not really short of breath but feels that she is aware of her breathing and the need to breathe. a. What is the nurses best reply? What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong 55. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2months. The nurses preliminary analysis, based on this history, is that this patient may be suffering from: a. Tuberculosis 56. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. a. Which of these findings is the nurse most likely to observe in this patient? Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema 57. A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: a. Postnasal drip or sinusitis. 58. During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate? a. Pulmonary edema 59. During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?a. Listening to at least one full respiration in each location 60. A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. a. The nurse expects to see which assessment findings related to this condition? Chest pain that is worse on deep inspiration and dyspnea 61. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: a. Crepitus 62. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are a. Atelectatic crackles that do not have a pathologic cause 63. A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. a. The nurse interprets this respiration pattern as which of the following? Hypoventilation 64. A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. a. What other key assessment finding would the nurse expect to find upon auscultation? Friction rub 65. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? a. SATA 3 answers: - Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in a very soft voice. - When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. - As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound. 66. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Although the stethoscope does not magnify sound, it does block out extraneous room noise67. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm a. Is used to listen for high-pitched sounds. 68. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation Cardiology 1. You are performing a thorough cardiac examination. a. Which of the following chambers of the heart can you assess by palpation? Right Ventricle 2. When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurses next action would be to a. Consider this finding normal in children and young adults 3. A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is: a. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts 4. A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that a. The blood pressure of a Black adult is usually higher than that of a White adult of the same age 5. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: a. Detect the presence of an auscultatory gap 6. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Bell of the stethoscope 7. What is responsible for the inspiratory splitting of S2? a. Closure of aortic, then pulmonic valves 8. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. a. Which valve is most likely to be involved, based on the location of the murmur?Mitral 9. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. a. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? Orthopnea 10. You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. a. How would you categorize this? Prehypertensive 11. You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. a. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease? Gender 12. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is wellcontrolled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. a. Which of the following conditions is considered to be a coronary heart disease risk equivalent? Peripheral arterial disease 13. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. a. Which one of the following characteristics is typical of the carotid pulse? Palpable 14. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated. a. Which one of the following conditions is a potential cause of elevated JVP? Constrictive pericarditis 15. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased.a. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse? Aortic stenosis, with pressure overload of the left ventricle 16. You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. a. Which of the following valvular defects is best heard in this position? Mitral 17. You are concerned that a patient has an aortic regurgitation murmur. a. Which is the best position to accentuate the murmur? Upright, but leaning forward 18. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. a. Which of the following conditions could be responsible for this heart rate? Second-degree A-V block 19. Where is the point of maximal impulse (PMI) normally located? a. In the left 5th intercostal space, 7 to 9 cm lateral to the sternum 20. Which of the following events occurs at the start of diastole? a. Closure of the aortic valve 21. Which is true of a third heart sound (S3)? a. It is caused by rapid deceleration of blood against the ventricular wall 22. Which is true of splitting of the second heart sound? a. It is best heard over the pulmonic area with the bell of the stethoscope. 23. Which of the following is true of jugular venous pressure (JVP) measurement? a. The vertical height of the blood column in centimeters, plus 5 cm, is the JVP 24. Which of the following regarding jugular venous pulsations is a systolic phenomenon? a. The “x” descent25. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure? a. 100% 26. In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines? a. Every 2 years 27. Which of the following is a clinical identifier of metabolic syndrome? a. BP of 134/88 for a male 28. Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. a. What heart rate should she achieve? 100 29. In measuring the jugular venous pressure (JVP), which of the following is important? a. Measure the highest visible pressure, usually at end expiration. 30. You find a bounding carotid pulse on a 62-year-old patient. a. Which murmur should you search out? Aortic insufficiency 31. To hear a soft murmur or bruit, which of the following may be necessary? a. All of the above: - Asking the patient to hold her breath - Asking the patient in the next bed to turn down the TV - Checking your stethoscope for air leaks 32. Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell? a. All of the above: - Mitral stenosis murmur - Opening snap of the mitral valve - S3 and S4 gallops 33. How should you determine whether a murmur is systolic or diastolic? a. Palpate the carotid pulse34. Which of the following correlates with a sustained, highamplitude PMI? a. Hypertension 35. You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. a. What should you do to obtain a good examination? Listen in the epigastrium 36. You are listening carefully for S2 splitting. a. Which of the following will help? Using the bell with light pressure over the 2nd left intercostal space 37. Which of the following is true of a grade 4-intensity murmur? a. It is associated with a “thrill.” 38. Which valve lesion typically produces a murmur of equal intensity throughout systole? a. Mitral insufficiency 39. You notice a patient has a strong pulse and then a weak pulse. This pattern continues. a. Which of the following is likely? Severe left heart failure 40. Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent and is located to the left of her sternum. There are no associated symptoms. On examination, you hear a short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2. This is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. a. Which of the following is the most likely diagnosis? Mitral valve prolapse 41. The sac that surrounds and protects the heart is called the: a. Pericardium 42. The direction of blood flow through the heart is best described by which of these? a. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle 43. The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? a. The atria contract toward the end of diastole and push the remaining blood into the ventricles.44. When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: a. Aortic and pulmonic 45. Which of these statements describes the closure of the valves in a normal cardiac cycle? a. The tricuspid valve closes slightly later than the mitral valve 46. The component of the conduction system referred to as the pacemaker of the heart is the a. Sinoatrial (SA) node 47. The electrical stimulus of the cardiac cycle follows which sequence? a. AV node SA node bundle of His bundle branches 48. The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: a. Elevated pressure related to heart failure Breast and Axillae 1. A 72-year-old retired saleswoman comes to your office, complaining of a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The patient denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetric, with no skin changes. You are able to express bloody discharge from her left nipple. You feel no discrete masses, but her left axilla has a hard, 1-cm fixed node. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. a. What cause of nipple discharge is the most likely in her circumstance? Breast cancer 2. A 44-year-old female comes to your clinic, complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self- examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Herpast medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. On examination you find a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczemalike crust around her nipple. Underneath you palpate a nontender2- cm mass. The axilla contains only soft, moveable nodes. The left breast and axilla examination findings are unremarkable. a. What visible skin change of the breast does she have? Paget's disease 3. A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self- examinations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable. a. What visible skin change of the breast does she have? Nipple retraction 4. A 19-year-old female comes to your office, complaining of a clear discharge from her right breast for 2 months. She states that she noticed it when she and her boyfriend were “messing around” and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetric with no skin changes. You are able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative.a. What cause of nipple discharge is the most likely in her circumstance? Benign breast abnormality 5. A 23-year-old computer programmer comes to your office for an annual examination. She has recently become sexually active and wants to be placed on birth control. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday nights. She denies any illegal drug use. On examination you see a mildly obese female who is breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark, velvet-like skin. Her annual examination is otherwise unremarkable. a. What disorder of the breast or axilla is she most likely to have? Acanthosis nigricans 6. A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut her hand gardening last week. a. What disorder of the axilla is most likely responsible for her symptoms? Lymphadenopathy of infectious origin 7. A 63-year-old nurse comes to your office, upset because she has found an enlarged lymph node under her right arm. She states she found itlast week while taking a shower. She isn't sure if she has any breast lumps because she doesn't know how to do self-exams. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-packs/year history. She denies using any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. On examination you see an older female appearing her stated age. On visual inspection of her right axilla you see nothing unusual. Palpating this area, you feel a 2-cm hard, fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of her right breast you feel a nontender 1-cm lump in the tail of Spence. a. What disorder of the axilla is most likely responsible for her symptoms? Breast Cancer 8. A 40-year-old mother of two presents to your office for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable. a. Which risk factor of her personal and family history most puts her in danger of getting breast cancer? First-degree relative with premenopausal breast cancer 9. A 51-year-old cook comes to your office for consultation. She recently found out that her 44- year-old sister with premenopausal breast cancer is positive for the BRCA1 gene. Your patient has been doing research on the Internet and saw that her chance of having also inherited the BRCA1 gene is 50%. She is interested in knowing what her risk of developing breast cancer would be if she were positive for the gene. She denies any lumps in her breasts and has had normal mammograms. She has had no weight loss, fever, or night sweats. Her mother is healthy and her father has prostate cancer. Two of herpaternal aunts died of breast cancer. She is married. She denies using tobacco or illegal drugs and rarely drinks alcohol. Her breast and axilla examinations are unremarkable. a. At her age, what is her risk of getting breast cancer if she has the BRCA1 gene? 50% 10. A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. On examination you see a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. a. What is the most likely cause of his gynecomastia? Imbalance of hormones of puberty 11. A patient is concerned about a dark skin lesion on her anterolateral abdomen. It has not changed, and there is no discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. a. What is this lesion? Supernumerary nipple 12. A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. a. What is the most likely diagnosis? Breast Tissue 13. Which of the following lymph node groups is most commonly involved in breast cancer? a. Central 14. When should a woman conduct breast self-examination with respect to her menses? a. Five to seven days following her menses 15. Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass.a. Without any other information, what is the risk of this mass being cancerous? About 10% 16. How often, according to American Cancer Society recommendations, should a woman undergo a screening breast examination by a skilled clinician? a. Every 3 years 17. Which of the following is most likely benign on breast examination? a. One breast larger than the other 18. Which is the most effective pattern of palpation for breast cancer? a. Examine in lines resembling the back and forth pattern of mowing a lawn 19. Which is true of women who have had a unilateral mastectomy? a. They should be examined carefully along the surgical scar for masses. 20. Which of the following is true regarding breast selfexamination? a. A high proportion of breast masses are detected by breast self-examination