Health Assessment Thorax & Lungs 2024/2025 | Complete Nursing Exam Questions with Answers (Graded A)

Downloaded by Mike Splendid () Health Assessment- Thorax and Lungs 1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: a. The spinous process of C7. b. Usually nonpalpable in most individuals. c. Opposite the interior border of the scapula. d. Located next to the manubrium of the sternum. The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. 2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b.Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest. The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema. 3. When assessing a patient's lungs, the nurse recalls that the left lung: a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobes. 4. Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL). The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7. 5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: a. Costal angle. b. Sternal angle. c. Xiphoid process. d.Suprasternal notch. The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back. 6. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: a. Adventitious sounds and limited chest expansion. b.Increased tactile fremitus and dull percussion tones. c. Muffled voice sounds and symmetric tactile fremitus. d. Absent voice sounds and hyperresonant percussion tones. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds 7. The primary muscles of respiration include the: a.Diaphragm and intercostals. b.Sternomastoids and scaleni. c.Trapezii and rectus abdominis. d.External obliques and pectoralis major. The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles—sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles. 8. 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. Obtaining a detailed health history of the patient's allergies and a history of asthma b. Telling the patient to sleep on his or her right side to facilitate ease of respirations c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week The patient is experiencing paroxysmal nocturnal dyspnea —being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.Downloaded by Mike Splendid () 9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Fifth intercostal space, midaxillary line (MAL) d. Over the lower lobes, posterior side Normally, fremitus is most prominent between the scapulae and around the sternum. These sites are where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progresses down the chest because more tissue impedes sound transmission. 10. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: a. "Is caused by moisture in the alveoli." b. "Indicates that air is present in the subcutaneous tissues." c. "Is caused by sounds generated from the larynx." d."Reflects the blood flow through the pulmonary arteries." Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues. 11. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: a. Shallow breathing. b. Normal lung tissue. c.Decreased adipose tissue. d.Increased density of lung tissue. A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Resonance is the expected finding in normal lung tissue. 12. 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 b.Top-to-bottom c.Posterior-to-anterior d.Interspace-by-interspace Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are not correct. 13. 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. The nurse interprets that these sounds are: a. Normally auscultated over the trachea. b. Bronchial breath sounds and normal in that location. c.Vesicular breath sounds and normal in that location. d.Bronchovesicular breath sounds and normal in that location. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where air flows through smaller bronchioles and alveoli. 14. The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b.Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the chest d. Lightly holding the bell of the stethoscope against the chest to avoid friction Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate. 15. 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. b.Tympany. c.Resonance. d.Hyperresonance. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. 16. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When the bronchial tree is obstructed b. When adventitious sounds are present c. In conjunction with whispered pectoriloquy d. In conditions of consolidation, such as pneumonia Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion. 17. The nurse knows that a normal finding when assessing the respiratory system of an older adult is:Downloaded by Mike Splendid () a.Increased thoracic expansion. b.Decreased mobility of the thorax. c.Decreased anteroposterior diameter. d.Bronchovesicular breath sounds throughout the lungs. The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter. 18. When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b.Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness and the patient's skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation. 19. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain. 20. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a.Airway obstruction b.Emphysema c.Pulmonary consolidation d. Asthma Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony 21. The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds a. Musical in quality. b. Usually caused by a pathologic disease. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration. Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly— between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct. 22. 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.Wheezes b.Bronchial sounds c.Bronchophony d.Whispered pectoriloquy Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema. 23. 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. Unequal chest expansion b.Increased tactile fremitus c.Atrophied neck and trapezius muscles d.Anteroposterior-to-transverse diameter ratio of 1:1 An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations 24. 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. The nurse interprets that these assessment findings are consistent with: a.Bronchitis. b.Pneumothorax. c.Acute pneumonia. d.Asthmatic attack. With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chestDownloaded by Mike Splendid () expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. 25. 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. The nurse interprets that these assessment findings are consistent with: a. Asthma. b.Atelectasis. c.Lobar pneumonia. d.Heart failure. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma. (See Table 18-8 for descriptions of the other conditions.) 26. 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. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. b. Respiratory muscle strength increases to compensate for a decreased vital capacity. c. Decrease in small airway closure occurs, leading to problems with atelectasis. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil. In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intraalveolar septa occurs, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload. 27. 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. What is the nurse's best reply? a. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." b. "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." c. "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." d. "This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate." During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mother's body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate. 28. 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 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: a.Bronchitis. b.Pneumonia. c.Tuberculosis. d.Pulmonary edema. Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. 29. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia 30. 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. Pneumonia. b. Postnasal drip or sinusitis.Downloaded by Mike Splendid () c. Exposure to irritants at work. d. Chronic bronchial irritation from smoking. A cough that primarily occurs at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day. 31. During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? a.Croup b.Tuberculosis c.Viral infection d.Pulmonary edema Sputum, alone, is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema or it may be a side effect of sympathomimetic medications. Croup is associated with a barking cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum. 32. 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 b.Listening as the patient inhales and then going to the next site during exhalation c.Instructing the patient to breathe in and out rapidly while listening to the breath sounds d.If the patient is modest, listening to sounds over his or her clothing or hospital gown During auscultation of breath sounds with a stethoscope, listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness. 33. A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b.Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes. 34. 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.Tactile fremitus. b.Crepitus. c.Friction rub. d.Adventitious sounds. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, such as after open thoracic injury or surgery. 35. 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. b.Fine crackles and may be a sign of pneumonia. c.Vesicular breath sounds. d.Fine wheezes. One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough. 36. 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. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Cheyne-Stokes respirations c.Hypoventilation d.Chronic obstructive breathing Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. 37. A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a.Stridor b.Friction rub c.Crackles d.WheezingDownloaded by Mike Splendid () A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases. Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema. 38. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. b. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. e. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound. As a patient repeatedly says "ninety-nine," normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-eeee" sound through auscultation, which is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this sound could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist. Health Assessment - Heart and Neck 1. While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse should document which of the following? A) Pericardial friction rub B) Midsystolic click C) Summation gallop D) Aortic ejection click 2. During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade? A) 1 B) 2 C) 3 D) 4 3. A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying this layer as which of the following? A) Myocardium B) Epicardium C) Endocardium D) Pericardium 4. A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which of the following locations? A) Bundle of His B) Purkinje fibers C) Sinoatrial node D) AV node 5. The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle? A) Isometric contraction B) Closure of the semilunar valves C) Beginning of diastole D) Closure of the atrioventricular valves 6. The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate? A) Increased jugular venous pressure B) Bradycardia C) Decreased blood pressure D) Dysrhythmias 7. The nurse is assessing a client with a cardiac condition who complains of not sleeping well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement? A) The client may have developed a cardiac conduction problem. B) The client may be experiencing symptoms of heart failure. C) The client's cardiac problem is being adequately compensated for. D) The client may be at increased risk for myocardial infarction. 8. The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse? A) Perform the exam with the client in a supine position. B) Have the client look straight ahead with chin slightlyDownloaded by Mike Splendid () lifted. C) Have the client sit up at a 90-degree angle. D) Inspect the suprasternal notch or around the clavicles. 9. The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location? A) Second intercostal space, left sternal border B) Third intercostal space, left axillary line C) Fourth intercostal space, left sternal border D) Fifth intercostal space, left midclavicular line 10. A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, which information would the nurse include? A) Caucasians usually possess greater lifestyle risks for CAD than African Americans. B) Hypertension is more prevalent in African Americans than among Caucasians. C) Hypertension is seen more in white women than in African-American women. D) Hispanic Americans have a higher rate of CAD than white Americans. 11. The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear? A) Split B) Diminished C) Accentuated D) Varying 12. The nurse is assessing a client who has a complex cardiac history. The nurse has asked the client to lean forward while in a sitting position. This position will allow the nurse to do which of the following? A) Assess the client's heart sounds while preventing shortness of breath. B) Identify heart sounds that may be inaudible in other positions. C) Assess the impact of the client's heart disease on his mobility. D) Differentiate heart sounds from breath sounds. 13. A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment? A) Start by auscultating the client's breath sounds. B) Auscultate prior to inspection and palpation. C) Use the bell rather than the diaphragm. D) Systematically listen to the entire precordium. 14. After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb's point? A) Fifth intercostal space near the left midclavicular line B) Third to fifth intercostal space at the left sternal border C) Second intercostal space at the right sternal border D) Second or third intercostal space at the left sternal border 15. A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization? A) P wave B) QRS complex C) ST segment D) T wave 16. The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate? A) Palpate each artery individually to compare. B) Palpate the arteries before auscultating them. C) Use the diaphragm of the stethoscope. D) Ask the client to breathe in and out deeply. 17. A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. Which of the following should the nurse do next? A) Inspect for a lift. B) Palpate for a thrill. C) Auscultate for pulse rate deficit. D) Listen for a ventricular gallop. 18. The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following? A) 1+ B) 2+ C) 3+ D) 4+ 19. A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2. Which of the following would be most appropriate for the nurse to do? A) Use the bell of the stethoscope to help distinguish the sounds. B) Palpate the carotid pulse while auscultating the heart. C) Determine the pulse deficit. D) Palpate the apical impulse. 20. A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations should the nurse include as appropriate for reducing a person's risk? Select all that apply. A) Avoid eating carbohydrates. B) Eat foods low in sodium. C) Walk for at least 30 minutes/day. D) Limit alcohol intake to 3 drinks per day. E) Use relaxation techniques to manage stress. 21. A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessments should focus on the signs and symptoms of what health problem? A) Myocardial infarction B) Heart failure C) Atherosclerosis D) Heart blockDownloaded by Mike Splendid () 22. The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the iA in this assessment model? B) In your experience, what kinds of activities tend to cause your chest pain? C) Would you describe your chest pain as being acute, or is it chronic? D) What changes do you have to make in order to accommodate your chest pain? 23. The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be normal in a healthy client? 27. The nurse is assessing an older adult client's heart and neck vessels. When attempting to palpate the client's apical impulse, what principle should guide the nurse's actions? A) The apical impulse will be irregular due to normal, agerelated physiological changes. C) The apical impulse will be found in a more medial location than in a younger client. D) The apical impulse will be easier to palpate if the client is in a standing position. 28. The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding? B) The jugular veins are fully distended when the client is in a high Fowler's position. C) The jugular veins are distended when the client sits at 45 degrees. D) The jugular venous pulse is visible when the client lies supine. 24. The nurse is assessing the carotid arteries of a client with a history of heart disease. What action should the nurse perform during this assessment? A) Palpate the client's left and right carotid arteries simultaneously. B) Palpate the client's carotid arteries prior to auscultation. C) Instruct the client to inhale and exhale forcefully during auscultation. 25. The nurse's auscultation of a 22-year-old client's apical heart rate reveals the presence of S3. When the client stands upright, the S3 is no longer audible. How should the nurse respond to this assessment finding? A) Make a referral to the client's primary care provider promptly. B) Perform a focused respiratory assessment. C) Recognize this as an early sign of left-sided heart failure. B) The client's aortic valve is incompetent. C) The client has left ventricular hypertrophy. D) The client's atria are not synchronized with the ventricles. 29. The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease? A) If you can eliminate red meat from your diet, your risk of heart disease will drop significantly. B) Try to ensure that you're screened for heart disease at least once every six months. C) Anything that you can do to reduce stress in your life will benefit your heart health. 30. The nurse has assessed a client's neck vessels and is now preparing to auscultate the client's heart sounds. What action should the nurse perform during this phase of assessment? A) Rapidly auscultate all areas of the precordium and then repeat the assessments in greater detail. B) Stand on the client's left side, nearest the heart. 26. The nurse is auscultating a client's heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur? A) Auscultate with the bell and then without the stethoscope. B) Ask the client to ìbear downî (perform the Valsalva maneuver) while auscultating. C) Ask the client to inhale and exhale deeply while auscultating. D) Begin by auscultating the entire precordium with the bell of the stethoscope. Health Assessment - Breast 1. Which of the following statements is true regarding the internal structures of the breast? The breast is made up of: a. Primarily muscle with very little fibrous tissue. c. Primarily milk ducts, known as lactiferous ducts. sweating? chest pain, such as nausea, A) Do you have any other symptoms together with your occlusion is audible. D) Palpate the client's carotid arteries gently if an client. D) Recognize this as a normal assessment finding in this b. Fibrous, glandular, and adipose tissues. positions D) Auscultate with the client in a variety of different able to stop smoking. D) Your risk for heart disease will drop greatly if you're simultaneously. is sitting upright. A) The client's ventricles are not contracting A) The jugular venous pulse is not visible when the client than in a younger client. B) The apical impulse may be more difficult to palpate C) Elevate the head of the client's bed to 30 degrees.Downloaded by Mike Splendid () d. Glandular tissue, which supports the breast by attaching to the chest wall. 2. In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: a. The largest quadrant of the breast. b. The location of most breast tumors. c. Where most of the suspensory ligaments attach. d. More prone to injury and calcifications than other locations in the breast. 3. In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular 4. If a patient reports a recent breast infection, then the nurse should expect to find node enlargement. a. Nonspecific b. Ipsilateral axillary c. Contralateral axillary d. Inguinal and cervical 5. A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, Am I normal? I dont seem to need a bra yet, but I have some friends who do. What if I never get breasts? The nurses best response would be: a. Dont worry, you still have plenty of time to develop. b. I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow. c. You will probably get your periods before you notice any significant growth in your breasts. d. I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age. 6. A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurses best response? Tell the mother that: a. Breast development is usually fairly symmetric and that the daughter should be examined right away. b. She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls. c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal. d. It is unusual for breasts that are first developing to feel tender because they havent developed much fibrous tissue. 7. A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that: a. The girl began to develop breasts. b. Her mother developed breasts. c. She began to develop pubic hair. d. She began to develop axillary hair. 8. A woman is in the family planning clinic seeking birth control information. She states that her breasts change all month long and that she is worried that this is unusual. What is the nurses best response? The nurse should tell her that: a. Continual changes in her breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long. b. Breast changes in response to stress are very common and that she should assess her life for stressful events. c. Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. d. Breast changes normally occur only during pregnancy and that a pregnancy test is needed at this time. 9. A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and immediately report these. d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth. 10. The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. Your breast milk is immediately present after the delivery of your baby. b. Breast milk is rich in protein and sugars (lactose) but has very little fat. c. The colostrum, which is present right after birth, does not contain the same nutrients as breast milk. d. You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy. 11. A 65-year-old patient remarks that she just cannot believe that her breasts sag so much. She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause: a. Only women with large breasts experience sagging. b. Sagging is usually due to decreased muscle mass within the breast. c. A diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. The glandular and fat tissue atrophies, causing breastDownloaded by Mike Splendid () size and elasticity to diminish, resulting in breasts that sag. 12. In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurses best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Ignore it. Benign breast enlargement in men is not unusual. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened. 13. During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Ask the young girl if her periods have started. b. Assess the girls weight and body mass index (BMI). c. Ask the girls mother at what age she started to develop breasts. d. Nothing; breast budding is a normal finding. 14. The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for developing breast cancer? a. Black b. White c. Asian d. American Indian 15. The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in black women in the United States? a. Breast cancer is not a threat to black women. b. Black women have a lower incidence of regional or distant breast cancer than white women. c. Black women are more likely to die of breast cancer at any age. d. Breast cancer incidence in black women is higher than that of white women after age 45 16. During a breast health interview, a patient states that she has noticed pain in her left breast. The nurses most appropriate response to this would be: a. Dont worry about the pain; breast cancer is not painful. b. I would like some more information about the pain in your left breast. c. Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct. d. Breast pain is almost always the result of benign breast disease. 17. During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Immediately contact the physician to report the discharge. b. Ask her if she is possibly pregnant. c. Ask the patient some additional questions about the medications she is taking. d. Immediately obtain a sample for culture and sensitivity testing. 18. During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask? a. Is the rash raised and red? b. Does it appear to be cyclic? c. Where did the rash first appear on the nipple, the areola, or the surrounding skin? d. What was she doing when she first noticed the rash, and do her actions make it worse? 19. A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? The presence of benign breast disease: a. Makes it hard to examine the breasts. b. Frequently turns into cancer in a womans later years. c. Is easily reduced with hormone replacement therapy. d. Is usually diagnosed before a woman reaches childbearing age. 20. During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms do a much better job than I ever could to find a lump. The nurse should explain to her that: a. BSEs may detect lumps that appear between mammograms. b. BSEs are unnecessary until the age of 50 years. c. She is correctmammography is a good replacement for BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually. 21. During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate? a. Breastfed babies tend to be more colicky. b. Breastfeeding provides the perfect food and antibodies for your baby. c. Breastfed babies eat more often than infants on formula. d. Breastfeeding is second nature, and every woman can do it.Downloaded by Mike Splendid () 22. The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37 year old who is slightly overweight b. 42 year old who has had ovarian cancer c. 45 year old who has never been pregnant d. 65 year old whose mother had breast cancer 23. During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Breasts should always be symmetric. b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. c. Asymmetry is not unusual, but the nurse should verify that this change is not new. d. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth. 24. The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? a. Woman whose nipples are in different planes (deviated). b. Woman whose left breast is slightly larger than her right. c. Nonpregnant woman whose skin is marked with linear striae. d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin. 25. During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. Whether the inversion is a recent change should be determined. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass. 26. The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: a. Bend over and touch her toes. b. Lie down on her left side and notice any retraction. c. Shift from a supine position to a standing position, and note any lag or retraction. d. Slowly lift her arms above her head, and note any retraction or lag in movement. 27. The nurse is palpating a female patients breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders 28. Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples 29. A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to: a. Palpate the lump first. b. Palpate the unaffected breast first. c. Avoid palpating the lump because it could be a cyst, which might rupture. d. Palpate the breast with the lump first but plan to palpate the axilla last. 30. The nurse has palpated a lump in a female patients right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 oclock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation? a. Shape of the lump b. Consistency of the lump c. Size of the lump d. Whether the lump is solitary or multiple 31. The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue.Downloaded by Mike Splendid () c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born. 32. The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct? a. BSE is more important than ever for you because you have never had any children. b. BSE is so important because one out of nine women will develop breast cancer in her lifetime. c. BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations. d. BSE will save your life because you are likely to find a cancerous lump between mammograms. 33. A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem flat and flabby. The nurses best reply would be: a. This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues. b. This is a normal change that occurs as women get older and is due to the increased levels of progesterone during the aging process. c. Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging. d. Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help prevent the changes in elasticity and size. 34. A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it was nothing to worry about. The examination validates the presence of a mass in the right upper outer quadrant at 1 oclock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. The nurse replies: a. Because of the change in consistency of the lump, it should be further evaluated by a physician. b. The changes could be related to your menstrual cycles. Keep track of the changes in the mass each month. c. The lump is probably nothing to worry about because it has been present for years and was determined to be noncancerous 5 years ago. d. Because you are experiencing no pain and the size has not changed, you should continue to monitor the lump and return to the clinic in 3 months. 35. During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate? a. The best time to examine your breasts is during ovulation. b. Examine your breasts every month on the same day of the month. c. Examine your breasts shortly after your menstrual period each month. d. The best time to examine your breasts is immediately before menstruation. 36. The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is: a. On the same day every month. b. Daily, during the shower or bath. c. One week after her menstrual period. d. Every year with her annual gynecologic examination. 37. While inspecting a patients breasts, the nurse finds that the left breast is slightly larger than the right with the bilateral presence of Montgomery glands. The nurse should: a. Palpate over the Montgomery glands, checking for drainage. b. Consider these findings as normal, and proceed with the examination. c. Ask extensive health history questions regarding the womans breast asymmetry. d. Continue with the examination, and then refer the patient for further evaluation of the Montgomery glands. 38. During an examination, the nurse notes a supernumerary nipple just under the patients left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. This variation is normal and not a significant finding. b. This finding is significant and needs further investigation. c. A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correcta supernumerary nipple is actually a mole that happens to be located under the breast. 39. While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: a. Dimpling. b. Retraction. c. Peau dorange. d. Benign breast disease. 40. When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurseDownloaded by Mike Splendid () is correct? The mother needs to: a. Continue to nurse on both sides to encourage milk flow. b. Immediately discontinue nursing to allow for healing. c. Temporarily discontinue nursing on the affected breast, and manually express milk and discard it. d. Temporarily discontinue nursing on affected breast, but manually express milk and give it to the baby. 41. A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3 C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget disease c. Plugged milk duct d. Mammary duct ectasia 42. During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it started doing that a few months ago. This finding suggests: a. Dimpling. b. Retracted nipple. c. Nipple inversion. d. Deviation in nipple pointing. 43. A 54-year-old man comes to the clinic with a horrible problem. He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true? a. Breast masses in men are difficult to detect because of minimal breast tissue. b. Breast cancer in men rarely spreads to the lymph nodes. c. One percent of all breast cancers occurs in men. d. Most breast masses in men are diagnosed as gynecomastia. 44. The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? Select all that apply. a. Nontender mass b. Dull, heavy pain on palpation c. Rubbery texture and mobile d. Hard, dense, and immobile e. Regular border f. Irregular, poorly delineated border 45. The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? Select all that apply. a. Malnutrition b. Hyperthyroidism c. Type 2 diabetes mellitus d. Liver disease e. History of alcohol abuse 46. An older woman is having an annual mammogram. Before the mammogram, the nurse does a breast examination. Expected normal findings would include: a. palpable, firm, stringy lactiferous ducts. b. increased glandularity. c. yellow colostrum expressed from the nipple. d. unilateral venous pattern. 47. The group of axillary lymph nodes that drains the other three groups of nodes is the: a. anterior nodes. b. central nodes. c. lateral nodes. d. posterior nodes. 48. The relative proportion of glandular, fibrous, and adipose breast tissue depends on: a. environmental factors. b. genetics. c. sex. d. nutritional state. 49. A known risk factor for breast cancer is: a. early menarche or late menopause. b. low breast tissue density. c. breastfeeding an infant for more than 6 months. d. low-fat, low-cholesterol diet. Health Assessment - Abdomen 1. During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate? A) Refer the client for medical follow-up. B) Evaluate further for a problem with the spleen. C) Assess urinary output. D) Document the position of the liver 2. When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A) Vitamin supplement with iron B) Nonsteroidal anti-inflammatory drug C) Antidepressant D) Hormone replacement 3. A group of students is preparing for their clinical experience, for which they are required to demonstrate theDownloaded by Mike Splendid () techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A) Palpate, percuss, inspect, auscultate B) Auscultate, inspect, palpate, percuss C) Inspect, auscultate, percuss, palpate D) Percuss, inspect, auscultate, palpate 4. Which strategy by the nurse would best facilitate palpation of a ticklish client's abdomen? A) Have client place hand on the abdomen with the nurse's hand on top. B) Press very firmly on the abdomen so the tickle sensation is absent. C) Distract the client with conversation about family while palpating the abdomen. D) Place a small amount of lubricant on the skin so the nurse's fingers will slide more easily. 5. To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do? A) Encourage the client to hold his or her breath. B) Cover the client in a warm blanket. C) Place a pillow under both of the client's knees. D) Assure the client that painful areas will not be examined. 6. A nurse suspects intra-abdominal bleeding in a client who was involved in a motor vehicle accident 3 days ago. Which finding would the nurse most likely have noted? A) Tenderness on palpation B) Diastasis recti C) Cullen's sign D) Tympany on percussion 7. A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following? A) Normoactive B) Hyperactive C) Hypoactive D) Absent 8. The nurse is percussing a client's' liver and is assessing liver descent. The nurse would have the client do which of the following? A) Cough forcefully B) Hold his or her breath C) Breathe deeply D) Perform the Valsalva maneuver 9. A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following? A) It is a normal-sized liver. B) The liver is larger than normal. C) The liver is smaller than normal. D) The liver has atrophied. 10. Which of the following would a nurse suspect if dullness is percussed at the last interspace at the anterior axillary line on deep inspiration? A) Hepatomegaly B) Splenomegaly C) Abdominal mass D) Intestinal air 11. While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following? A) Hernia B) Malignancy C) Infection D) Aneurysm 12. The nurse is preparing to assess the size of the aorta. The nurse would palpate at which location? A) Midline at the umbilicus B) Deep epigastrium to the left of midline C) Slightly above the suprapubic area D) Between the umbilicus and the symphysis pubis 13. Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance. 14. A nurse is preparing to palpate a client's spleen. Which position would the nurse use to facilitate palpation? A) Sitting B) Lying prone C) Left side-lying D) Right side-lying 15. A client's bladder is found to be distended. At which location would the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant 16. Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions? A) Shifting dullness B) Fluid wave C) Abdominal x-ray D) Ultrasound 17. The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location? A) Right upper quadrant B) Left upper quadrantDownloaded by Mike