Exam 3: NSG3160 / NSG 3160 (Latest 2026 / 2027) Health Assessment | 100% Correct Questions & Answers - Galen

Exam 3: NSG3160 / NSG 3160 (Latest 2026 / 2027) Health Assessment | 100% Correct Questions & Answers - Galen Question: Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: Answer The spinous process of C7. 3 multiple choice options Question: When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: Answer A normal finding in a healthy adult. 3 multiple choice options Question: When assessing a patients lungs, the nurse recalls that the left lung: Answer Consists of two lobes. 3 multiple choice options Question: Which statement about the apices of the lungs is true? The apices of the lungs: Answer Extend 3 to 4 cm above the inner third of the clavicles. 3 multiple choice options Question: During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: Answer Sternal angle 3 multiple choice options Question: During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: Answer Muffled voice sounds and symmetric tactile fremitus. 3 multiple choice options Question: The primary muscles of respiration include the: Answer Diaphragm and intercostals. 3 multiple choice options Question: Question: 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? Answer Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea 3 multiple choice options Question: When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? Answer Between the scapulae 3 multiple choice options Question: 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: Answer Is caused by sounds generated from the larynx. 3 multiple choice options Question: Tactile Fremitus is what? Answer Palpable vibration Question: During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: Answer Increased density of lung tissue. 3 multiple choice options Question: 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. Answer Side-to-side 3 multiple choice options Question: 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: Answer Vesicular breath sounds and normal in that location. 3 multiple choice options Question: 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: Answer Dullness 3 multiple choice options Question: The nurse is auscultating the chest in an adult. Which technique is correct? Answer Firmly holding the diaphragm of the stethoscope against the chest 3 multiple choice options Question: During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? Answer When the bronchial tree is obstructed 3 multiple choice options Question: The nurse knows that a normal finding when assessing the respiratory system of an older adult is: Answer Decreased mobility of the thorax. 3 multiple choice options Question: 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. The nurses next action should be to: Answer Recognize that these are serious signs, and contact the physician. 3 multiple choice options When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? Answer Presence of bronchovesicular breath sounds in the peripheral lung fields 3 multiple choice options When inspecting the anterior chest of an adult, the nurse should include which assessment? Answer Shape and configuration of the chest wall 3 multiple choice options The nurse knows that auscultation of fine crackles would most likely be noticed in: The immediate newborn period. 3 multiple choice options During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? When part of the lung is obstructed or collapsed 3 multiple choice options 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? Pulmonary consolidation 3 multiple choice options The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are: Expected near the major airways. 3 multiple choice options 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? Wheezes 3 multiple choice options A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? Anteroposterior-to-transverse diameter ratio of 1:1 3 multiple choice options 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: Pneumothorax. With a pneumothorax free air in the pleural space causes partial or complete lung collapse Presence of pneumothorax. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds 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: Asthma 3 multiple choice options The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? Lungs are less elastic and distensible, which decreases their ability to collapse and recoil. 3 multiple choice options 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 nurses preliminary analysis, based on this history, is that this patient may be suffering from: Tuberculosis 3 multiple choice options 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? Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema 3 multiple choice options 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 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: Postnasal drip or sinusitis. 3 multiple choice options During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate? Pulmonary edema 3 multiple choice options During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? Listening to at least one full respiration in each location 3 multiple choice options 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? Chest pain that is worse on deep inspiration and dyspnea 3 multiple choice options During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin Crepitus 3 multiple choice options 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: Atelectatic crackles that do not have a pathologic cause. 3 multiple choice options 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? Hypoventilation 3 multiple choice options Hypoventilation is characterized 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. 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? Friction rub 3 multiple choice options Normal respiratory sounds during a respiratory assessment? -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. 2 multiple choice options Which of the following statements is true regarding the internal structures of the breast? The breast is made up of: Fibrous, glandular, and adipose tissues. 3 multiple choice options 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: The location of most breast tumors. 3 multiple choice options In performing an assessment of a womans axillary lymph system, the nurse should assess which of these nodes? Central, lateral, pectoral (anterior), and subscapular(Posterior) 3 multiple choice options Women's axillary lymph system (4 groups) Central, Pectoral, Subscapular"posterior", Lateral (Cats, Pee, Stinks, Lots) If a patient reports a recent breast infection, then the nurse should expect to find ________ node enlargement. Ipsilateral axillary 3 multiple choice options 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: I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age. 3 multiple choice options 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: Although an examination of her daughter would rule out a problem, her breast development is most likely normal. 3 multiple choice options One breast asymmetry temporary and tenderness Often common, reassurance is necessary 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: The girl began to develop breasts. 3 multiple choice options 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: Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. 3 multiple choice options A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? She can expect her areolae to become larger and darker in color. 3 multiple choice options The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy. 3 multiple choice options 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: The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag 3 multiple choice options 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? Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. 3 multiple choice options Gynecomastia may reappear in the aging Men 2 multiple choice options 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? Assess the girls weight and body mass index (BMI). 3 multiple choice options BMI (body mass index) ranges 18.5 = Underweight 18.5 to 24.9 = Healthy 25 to 29.9 = Overweight 30 to 34.9 = Obese 35 = Severe obesity 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? Black 3 multiple choice options White women have a higher incidence of breast cancer than black women starting at age 45 years but black women have a higher incidence before age 45 years 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? Black women are more likely to die of breast cancer at any age. 3 multiple choice options 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: I would like some more information about the pain in your left breast. 3 multiple choice options 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? Ask the patient some additional questions about the medications she is taking. 3 multiple choice options Oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers May cause clear nipple discharge 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? Where did the rash first appearon the nipple, the areola, or the surrounding skin? 3 multiple choice options Paget disease Small crust on the nipple apex and then spreads to the areola 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: Makes it hard to examine the breasts. 3 multiple choice options 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: BSEs may detect lumps that appear between mammograms. 3 multiple choice options 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? Breastfeeding provides the perfect food and antibodies for your baby. 3 multiple choice options Exclusively breastfeeding for 6 months can.. decreases the risk of ear infections, promotes bonding, and provides relaxation. (perfect food and antibodies) 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? 65 year old whose mother had breast cancer 3 multiple choice options 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? Asymmetry is not unusual, but the nurse should verify that this change is not new. 3 multiple choice options The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? Woman whose nipples are in different planes (deviated). 3 multiple choice options During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? Whether the inversion is a recent change should be determined. 3 multiple choice options 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: Slowly lift her arms above her head, and note any retraction or lag in movement. 3 multiple choice options 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? Supine with the arms raised over her head 3 multiple choice options Which of these clinical situations would the nurse consider to be outside normal limits? 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. 3 multiple choice options 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: Palpate the unaffected breast first. 3 multiple choice options 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? Size of the lump 3 multiple choice options If the nurse feels a lump or mass, then he or she should note these characteristics: (1) location, (2) sizejudge in centimeters in three dimensions: width length thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy. The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. 3 multiple choice options The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct? BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations. 3 multiple choice options 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: Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging. 3 multiple choice options 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: Because of the change in consistency of the lump, it should be further evaluated by a physician. 3 multiple choice options During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate? Examine your breasts shortly after your menstrual period each month. 3 multiple choice options The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is: On the same day every month. 3 multiple choice options 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: Consider these findings as normal, and proceed with the examination. 3 multiple choice options 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? This variation is normal and not a significant finding. 3 multiple choice options 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: Peau dorange. 3 multiple choice options When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: Temporarily discontinue nursing on the affected breast, and manually express milk and discard it. 3 multiple choice options 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? Mastitis 3 multiple choice options 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: Retracted nipple. 3 multiple choice options 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? One percent of all breast cancers occurs in men. 3 multiple choice options 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. Nontender mass, Hard, dense, and immobile, Irregular, poorly delineated border 3 multiple choice options Cancerous breast masses are.. solitary, unilateral, and nontender 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. Hyperthyroidism, Liver disease, History of alcohol abuse 2 multiple choice options Gynecomastia occurs with Cushing syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, and numerous drugs, such as alcohol and marijuana use, estrogen treatment for prostate cancer, antibiotics (metronidazole, isoniazid), digoxin, angiotensin-converting enzyme (ACE) inhibitors, diazepam, and tricyclic antidepressants. The sac that surrounds and protects the heart is called the: Pericardium 3 multiple choice options The direction of blood flow through the heart is best described by which of these? Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle 3 multiple choice options The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? The atria contract toward the end of diastole and push the remaining blood into the ventricles. 3 multiple choice options When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: Aortic and pulmonic. 3 multiple choice options Which of these statements describes the closure of the valves in a normal cardiac cycle? The tricuspid valve closes slightly later than the mitral valve. 3 multiple choice options The component of the conduction system referred to as the pacemaker of the heart is the: Sinoatrial (SA) node. 3 multiple choice options The electrical stimulus of the cardiac cycle follows which sequence? AV node SA node bundle of His bundle branches 3 multiple choice options 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: Elevated pressure related to heart failure. 3 multiple choice options When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true? Blood can flow into the left side of the heart through an opening in the atrial septum. 3 multiple choice options A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? This decline in blood pressure is the result of peripheral vasodilatation and is an expected change. 3 multiple choice options In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? Increase in systolic blood pressure 3 multiple choice options With aging an increase in systolic blood pressure occurs. A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. Ill be sleeping great, and then I wake up and feel like I cant get my breath. The nurses best response to this would be: Do you have any history of problems with your heart? 3 multiple choice options In assessing a patients major risk factors for heart disease, which would the nurse want to include when taking a history? Smoking, hypertension, obesity, diabetes, and high cholesterol 3 multiple choice options The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have? Presence of dyspnea or diaphoresis when sucking 3 multiple choice options In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: Listen with the bell of the stethoscope to assess for bruits. 3 multiple choice options During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: Blood flow turbulence. 3 multiple choice options During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n): Enlargement of the right ventricle. 3 multiple choice options During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? Fifth left intercostal space at the midclavicular line 3 multiple choice options The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? Studies show that percussed cardiac borders do not correlate well with the true cardiac border. 3 multiple choice options The nurse is preparing to auscultate for heart sounds. Which technique is correct? Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex 3 multiple choice options While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurses response? No further response is needed because sinus arrhythmia can occur normally. 3 multiple choice options When listening to heart sounds, the nurse knows that the S1: Coincides with the carotid artery pulse. 3 multiple choice options During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do? Watch the patients respirations while listening for the effect on the sound. 3 multiple choice options Which of these findings would the nurse expect to notice during a cardiac assessment on a 4 year-old child? Murmur at the second left intercostal space when supine 3 multiple choice options While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings? These findings can all be normal in a child. 3 multiple choice options During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: Displacement of the heart from elevation of the diaphragm. 3 multiple choice options In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: Bell of the stethoscope at the apex with the patient in the left lateral position. 3 multiple choice options A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patients history, the nurse knows that this extra heart sound is most likely a(n): Atrial gallop. 3 multiple choice options The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: Inflammation of the precordium. 3 multiple choice options The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? Tetralogy of Fallot 3 multiple choice options A 30-year-old woman with a history of mitral valve problems states that she has been very tired. She has started waking up at night and feels like her heart is pounding. During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with: Mitral regurgitation. 3 multiple choice options During a cardiac assessment on a 38-year-old patient in the hospital for chest pain, the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? Heart failure 3 multiple choice options The nurse knows that normal splitting of the S2 is associated with: Inspiration 3 multiple choice options During a cardiovascular assessment, the nurse knows that a thrill is: Vibration that is palpable. 3 multiple choice options During a cardiovascular assessment, the nurse knows that an S4 heart sound is: Heard at the end of ventricular diastole. 3 multiple choice options During an assessment, the nurse notes that the patients apical impulse is laterally displaced and is palpable over a wide area. This finding indicates: Volume overload, as in heart failure. 3 multiple choice options When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique? While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. 3 multiple choice options The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? African american 3 multiple choice options The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patients abdomen, just below the rib cage? The jugular veins will remain elevated as long as pressure on the abdomen is maintained. 3 multiple choice options The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as: Normal for this age. 3 multiple choice options The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI? Select all that apply. Abnormal lipids, Smoking, Hypertension, Diabetes 3 multiple choice options The nurse is assessing a patients pulses and notices a difference between the patients apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105 beats per minute. What is the pulse deficit? 13 3 multiple choice options Which statement is true regarding the arterial system? The arterial system is a high-pressure system. 3 multiple choice options The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. Brachial 1 multiple choice option The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? Lateral to the extensor tendon of the great toe 3 multiple choice options A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _______ the left leg. Ischemia caused by a partial blockage of an artery supplying 3 multiple choice options The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? Intraluminal valves ensure unidirectional flow toward the heart. 3 multiple choice options Which vein(s) is(are) responsible for most of the venous return in the arm? Superficial 3 multiple choice options A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, What happens to my circulation when this vein is removed? The nurse should reply: This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition. 3 multiple choice options The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? Person who has been on bed rest for 4 days 3 multiple choice options The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? The flow of lymph is slow, compared with that of the blood. 3 multiple choice options When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? Examine the patients lower arm and hand, and check for the presence of infection or lesions. 3 multiple choice options A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? Enlarged and tender inguinal nodes 3 multiple choice options The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? Presence of palpable lymph nodes 3 multiple choice options During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure 3 multiple choice options A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: Claudication 3 multiple choice options A patient complains of leg pain that wakes him at night. He states that he has been having problems with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed a sore on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing: Problems related to arterial insufficiency. 3 multiple choice options During an assessment, the nurse uses the profile sign to detect: Early clubbing. 3 multiple choice options The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? Consider this a delayed capillary refill time, and investigate further. 3 multiple choice options When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? Auscultate the site for a bruit. 3 multiple choice options When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patients skin is warm and capillary refill time is normal. Next, the nurse should: Consider this finding as normal, and proceed with the peripheral vascular evaluation. 3 multiple choice options The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse. Bounding 3 multiple choice options The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? To evaluate the adequacy of collateral circulation before cannulating the radial artery 3 multiple choice options A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? Brownish discoloration to the skin of the lower leg 3 multiple choice options The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? The patient is asked to bend his or her knees to the side in a froglike position. 3 multiple choice options When auscultating over a patients femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits: Occur with turbulent blood flow, indicating partial occlusion. 3 multiple choice options How should the nurse document mild, slight pitting edema the ankles of a pregnant patient? 1+/0-4+ 3 multiple choice options A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: Nonpitting, hard edema occurs with lymphatic obstruction. 3 multiple choice options When assessing a patients pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: Paradoxus 3 multiple choice options During an assessment, the nurse has elevated a patients legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be: Venous filling within 15 seconds. 3 multiple choice options During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel heavy in the calf and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? Varicose veins 3 multiple choice options During an assessment, the nurse notices that a patients left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? Lymphedema 3 multiple choice options The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication. 3 multiple choice options The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient? Palpable firm, small, shotty, mobile, and nontender lymph nodes 3 multiple choice options When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? Swishing, whooshing sound 3 multiple choice options The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? Is hard to palpate, may fade in and out, and is easily obliterated by pressure. 3 multiple choice options During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: Raynaud disease. 3 multiple choice options During a routine office visit, a patient takes off his shoes and shows the nurse this awful sore that wont heal. On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well- defined edges, and no drainage. The nurse should assess for other signs and symptoms of: Arterial ischemic ulcer. 3 multiple choice options The nurse is reviewing an assessment of a patients peripheral pulses and notices that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse? Normal 3 multiple choice options +1 Weak pulse 2+ bounding pulse Normal pulse A patient is recovering from several hours of orthopedic surgery. During an assessment of the patients lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. Intense, sharp pain, with the deep muscle tender to the touch, Sudden onset, Warm, red, and swollen calf 3 multiple choice options A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. Patient has a history of diabetes and cigarette smoking., Skin of the patient is pale and cool., He states that the pain gets worse when walking. 3 multiple choice options 1. What are the modifiable risks of CAD (coronary artery disease) Smoking, obesity, hypertension, high cholesterol, diabetes 2. Does pain always mean cardiac reasons? What should you ask if patient is experiencing chest pain? NO - Is it sudden? What brings it on? 3. Signs of pulmonary embolism? Sharp, stabbing pain that worsens with deep breath 4. Signs of pneumonia? Sharp, stabbing, but associated with a cough 5. Signs of pneumothorax? Acute, sudden, sharp 6. Signs of GI-related? Burning sensation with eating large meals 7. What is S1 and what causes the sound? Start of systole and serves as a reference point for Oming of all cardiac sounds - Caused by the closure of AV valves - LUB (apex) 8. What causes the sound of S2? Closure of the semilunar valves - DUB (base) 9. What are summation sounds? When both the pathological S3 and S4 are present then a quadruple rhythm is heard 10. What is a murmur? Occurs with turbulent blood flow in the heart - Blowing, swooshing sound 11. What is pericardial friction rub? Inflammation of the pericardium gives rise to friction rub - High pitched and scratchy, heard with a diaphragm when a person is sitting up 12. What are the locations of the heart valves? Aortic: second right interspace -----Pulmonic: second left interspace-------- Erbs: third left interspace----- Tricuspid: left lower sternal border ----- Mitral: Fifth interspace around the left midclavicular line 13. What should you do when you hear a split S2 and when does it occur? Concentrate on the split as you watch the person's chest rise up and down with normal breathing---Every fourth heartbeat fading in with inhalation and fading out with exhalation 14. What should you NOT do when hearing a split S2? DO NOT have the person hold their breath-- Breath-holding only equalizes ejection times in the right and left sides of the heart and causes the split to go away. 15. What is a thrill? Palpable vibration, feels like the throat of a purring cat 16. What is a thrill caused by? Turbulent blood flow and directs you to locate the origin of loud murmurs 18. What is apical impulse and how to assess it? Palpate left of the sternal border down the midclavicular line between the 4th and 5th intercoastal space. 19. What position should you have a patient in when estimating jugular venous pressure? 45 degrees 20. How much exercise should you teach your patient? 5 times a week, at least 30 minutes each time 21. Why should patients take low-dose aspirin every day? Control BP 22. What should you teach if the patient smokes? Teach about smoking cessation and exercise 23. What are key expected findings cardiac-wise, in an older patient?, Increase in systolic pressure from arteriosclerosis - The presence of supraventricular dysrhythmias increases - EEG from changes in the conduction system - OrthostaOc hypotension 24. What do you want to educate an older patient about? Take their time when moving from sitting to supine and from sitting to standing positions due to orthostatic hypotension - Put call light on to have staff help get up to prevent falls 25. What is arteriosclerosis? Thickening/stiffening of arteries caused by collagen and calcium deposits, loss of elasticity 26. How should you assess carotid pulse? One at a time to avoid having the patient pass out. 27. What is a pulse deficit and how do you figure it out? Difference from apical and radial pulse = pulse deficit & Irregularity What are the aggravating and relieving factors of chronic arterial (PAD)? a. Aggrivating - activity, elevation b. Relieving factors - Rest What are the symptoms of PAD? a. Low ankle-brachial index, cool pale skin, diminished pulse, pallor on elevation What are the aggravating and relieving facts of chronic venous? a. aggravating - Prolonged standing and sitting b. Relieving -Elevation, lying, walking What are the symptoms of chronic venous? a. Edema, varicosis, weeping ulcers at ankles. What type of edema will you see with lymphatic obstruction? a. Unilateral What is a normal capillary refill? a. Less than 1-2 seconds What can cause a longer capillary refill? a. Environment can be cold, vasoconstriction b. Cigarette smoking c. Edema, anemia from decreased oxygen to tissues When and how to use a portable Doppler ultrasound? a. When unable to palpate a pulse b. Apply gel onto the site, and put the wand on there, will be audible. What will blood flow sound like with a portable Doppler ultrasound? a. Swishing, whooshing sound What does the Wells Score of DVT indicate? a. 1-2 -moderate probability b. 3 or more - a high probability How do you assess epitrochlear nodes? a. "Shaking hands", reach hand under the patient's elbow and into the groove between the biceps and triceps b. You should NOT feel any lymph nodes What are the 4.0 risk factors for breast cancer? a. Dense breasts = harder to pick up the diagnosis b. Age 65+ c. Genetic mutations - BRCA1 or BRCA 2 d. Two or more first-degree relative with breast cancer diagnosed at an early age e. Personal history Why would we teach patients to palpate into the axillary area when they perform a self-breast exam? a. Deep muscles and tail of Spence that extends into the area. When finding NEW onset nipple discharge, what should you do? a. Get a specimen and send it off to the lab, could indicate a mass How should you palpate the breast? a. Supine position with arm over head, pillow behind shoulder How do you palpate axillary lymph nodes? a. Patient sitting, b-e. Along chest wall and borders of axilla and inner aspect of upper arm What is crepitus? a. Coarse, crackling sensation felt during palpation What is fremitus? a. Vibration transmitted through body When does decreased fremitus occur? a. Obstructed bronchus, pleural effusion or thickening, pneumothorax or emphysema, b. Any barriers between sound and your palpating hand When does increased fremitus occur? a. Compression or consolidation of lung tissue What is bronchophony and what are the normal findings? a. Ask person to repeat ninety-nine while listening with stethoscope over chest wall, b. NORMAL - soft, muffled, distinct What is egophony and what are the normal findings? a. Auscultate chest while person phonates a long 'ee-ee-ee-ee' sound, b. NORMAL - Eeeeeee What is whispered pectoriloquy? a. Ask person to whisper a phrase like one-two-three, b. NORMAL - Faint, muffled, inaudible What are the characteristics of bronchial (tracheal) breath sounds? a. PITCH - High, b. AMPLITUDE - Loud, c. DURATION - Inspiration Expiration, d. QUALITY - Harsh, hollow tubular, e. NORMAL LOCATION - Trachea and larynx What are the characteristics of bronchovesicular breath sounds? a. PITCH - Moderate, b. AMPLITUDE - Moderate, c. DURATION - Inspiration = Expiration, d. QUALITY - Mixed, e. NORMAL LOCATION - Over major bronchi (fewer alveoli), around upper sternum in 1st and 2nd intercoastal spaces What are the characteristics of vesicular breath sounds? a. PITCH - Low, b. AMPLITUDE - Soft, c. DURATION - Inspiration Expiration, d. QUALITY - Rustling, like the sound of the wind in the trees, e. NORMAL LOCATION - Over peripheral lung fields where air flows through smaller bronchioles and alveoli What is amplitude? Soft What is duration? Inspiration Expiration What is quality? Rustling sound of wind in trees What is normal location? Over peripheral lung fields when air flows through smaller bronchioles and alveoli What is tactile fremitus? Palpable vibration from the larynx How is tactile fremitus assessed? Use a palmar base of the fingers and have the patient say 'ninety-nine'. Vibrations should feel the same in the corresponding areas on each side How is diaphragmatic excursion done? Assessing the posterior side How should you assess chest expansion? Place thumbs together posteriorly on the thoracic cage and have the patient take a deep breath. NORMAL - Hands move apart symmetrically What is resonance? Low-pitched, clear, hollow sounds that predominated in healthy lung tissue in adult What is hyper-resonance? Lower pitched, booming sound found when too much air is present such as in emphysema or pneumothorax What is dullness? Soft muffled thud. Signals of abnormal density in the lungs (EX: pneumonia, pleural effusion, atelectasis, tumor) What is a tympany? High pitched with longer duration than resonance and hyper resonance, sounds like a drum. Normally heard over fluid-filled organs such as the stomach, bladder, and bowels What is tachypnea? Rapid, shallow breathing. Increased rate 24 per minute What is bradypnea? Slow breathing. Decreased but regular rate 10 per minute What are Cheyne Stokes's Respirations? Respirations gradually wax and wane in a regular pattern increasing in rate and depth then decreasing. Periods of apnea of 20 seconds. Causes - Severe heart failure, renal failure, meningitis, drug overdose, intracranial pressure What is chronic obstructed breathing? Air trapping. Caused by COPD What are fine crackles lung sounds? High-pitched, discontinuous, popping lung sounds heard during inspiration. Caused by fluid in the alveoli or delayed reopening of the airways. What are crackles lung sounds? Discontinuous, high-pitched short crackling, popping sounds heard during inspiration that is not cleared by coughing. What are coarse crackles lung sounds? Loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in the expiration. What is pleural friction rub lung sound? Superficial sound that is coarse and low-pitched, grating quality as if two pieces of leather is being rubbed together. What is high pitched wheezing lung sound? High-pitched, musical squeaking sounds that sound polyphonic. Predominate in expiration. What is low pitched wheezing lung sound? Low-pitched, monophonic single note, musical snoring, moaning sounds. Heard throughout the cycle. May clear somewhat with coughing. What is stridor lung sound? High-pitched, monophonic inspiratory, crowing sounds; louder in neck than over chest wall. What are rhonchi? Low-pitched, musical sounds similar to snores. Often cleared by coughing. What is the normal AP diameter? 1:2. What is a barrel chest? Equal in AP to transverse diameter. What are some respiratory changes that occur in older adults? Kyphosis, dyspnea. Decreased vital capacity. Increased residual volume. Less surface area for gas exchange. Decrease in elastic properties in lungs, less distensible. More rigid structure. What does distensible mean? Not being able to distend, stretch. What do all of the respiratory changes in older adults cause? Risk for complications, especially post-op. Learn More You can also click on terms or definitions to blur or reveal them Review with an activity