Exam 2 Flashcards
Which description would be characteristic of fibroadenoma?
Freely movable and feels firm and elastic
Which vitamin deficiency would possibly cause xerophthalmia?
Vitamin A
Which term describes the thin layer of endothelial tissue that lines the inner surface of the heart and valves?
Endocardium
Which nutritional deficiency would contribute to osteoporosis in older adult patients?
Vitamin D and Calcium
Which organ would be located in all four quadrants of the abdomen?
Small intestines
Which feature would be characteristic of the great saphenous vein?
Located inside the leg
For which reason would an adolescent patient diagnosed with an upper respiratory tract infection complain of abdominal pain?
Inflammation of the mesenteric lymph nodes
Intercostal spaces are numbered based on which structures?
Ribs present above the spaces
Which microorganism would cause athlete’s foot?
Tinea Pedis
Which nutrient deficiency would cause papillary atrophy in a patient?
Niacin
What term would be used to document the patient’s report of painful breasts?
Mastalgia
Which structure separates the thoracic cavity from the abdomen?
The Diaphragm
Which illicit drug would be most commonly used in the United States?
Cannabis
Which method for obtaining information about dietary intake is a patient who has listed all foods eaten in the past 24 hours?
Obtaining a 24-hour recall
Which asymmetry of a patient’s calf measurements would reflect moderate lymphedema?
4.0 cm
Which medication would be a safety measure for a patient who uses oral contraceptives and is at risk for deep vein thrombosis?
Clopidogrel (Plavix)
What type of injury would be caused by friction?
Rug Burn
Wich location would the Montgomery glands be found?
Areola
What type of abuse would the nurse suspect when finding burns and belt marks on the back of a child patient?
Physical
Which soft-lobulated gland would be located behind the stomach?
Pancreas
Which intervention would the nurse perform when collecting a history from an abused 7-year-old with a hand injury?
Use simple language
While assessing a patient with an infection of the forearm, for which reason would the nurse use one hand to shake the patient’s hand and keep the other hand near the patient’s elbow?
Assess for enlarged epitrochlear nodes
Which condition would be suspected in an infant with enlarged, warm, and tender cervical lymph nodes?
Respiratory infection
What finding would support the nurse’s suspicion of pulsus paradoxes in a patient diagnosed with acute asthma?
Blood pressure decreases 10 mm Hg during inspiration
The goblet cells of the lungs serve which purpose?
Entrap small particulate matter
Which site would be appropriate for palpation of the popliteal pulse?
Below the knee
The accumulation of lymph in the breasts and upper arms would be due to an obstruction of which lymph nodes?
Axillary
What value of HDL in a male patient would qualify as a biomarker for metabolic syndrome?
mg/dL
Which purpose would the Cooper ligaments in the breast serve?
Support Breast tissue
Which finding would indicate a normal value for the breath alcohol analysis test?
0.00
Which intervention would the nurse perform when screening patients for intimate partner violence?
Focus on Males and Females
What feature would be specific to the right kidney?
May be palpable
To determine the development of tolerance with using the Tolerance, Worry, Eye-Opener, Amnesia, Kut down (TWEAK) questionnaire, which minimum number of drinks would the patient consume?
3
Where is the central axillary node of the breast located?
Over the ribs and serratus anterior muscle
Which type of abuse would involve belittling and threatening?
Emotional
Which intervention would the nurse perform for a child who has been abused?
Inform the legal authorities
Which finding would the nurse relate to Cushing syndrome during an assessment?
Purple-blue striae
Which tool collects dietary information without providing any information on the quantity of food consumed?
Food Frequency questionnaire
What PT assessment would the nurse report as a normal skin finding?
smooth firm skin
Which cause would be associated with a carked visible peristalsis?
intestinal obstruction
What skin color would the nurse observe in a child being fed vitamin A supplements regularly?
Yellowish-Orange
Which description of hypercapnia is correct?
increased carbon dioxide in the blood
Which type of drinker would describe a male who consumes two drinks a day?
Moderate
What substance would be the most used and abused psychoactive drug in the United States?
Alcohol
Which parameter would the nurse assess to determine the “W” in the TWEAK questionnaire?
Worry
Which condition would the nurse anticipate when auscultating diminished bowel sounds?
Peritonitis
How many thoracic vertebrae are present in the human body
12
Which part of the breast is called the tail of the Spence?
The superior lateral corner
Which physiological condition is the most common nutritional concern in the United States?
Overnutrition
Which medical condition would be a major cause of liver cirrhosis
Alcohol abuse
during the chest assessment of a patient, which reference line would the nurse note on the posterior chest wall?
Midspinal
Which initial intervention would the nurse perform to confirm the position of the patient’s feeding tube prior to using it for the first time?
obtain a chest x-ray
For which type of abuse would the nurse be assessing when asking the following question from the Elder Abuse Suspicion Index (EASI): Have you been upset because someone talked to you in a way that made you feel ashamed or threatened?
psychological
Which condition is associated with a triceps skinfold (TSF) of 10% above the standard?
Overnutrition
Which location is the human heart found?
Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line.
If properly treated, how long does it take to resolve a plugged duct in the breast?
Less than a day
Which resource standard would the nurse use for an adult female patient who is hesitating to file an abuse complaint against their partner because of immigration status?
Violence Against Women Act
What disorder would cause calcification of the arteries?
Diabetes mellitus
What assessment tool would the nurse suggest the patient use to obtain a thorough history of food consumed?
Food Diary
Which patient population is most likely to be affected by scoliosis?
Adolescents
Which blood vessel drains the blood from the head and upper extremities?
Superior vena cava
Which statement is true regarding the right lung?
It is shorter than the left lung
Which would the nurse assess first in the patient during a regional cardiovascular assessment?
Pulse and Blood Pressure
Which part of the lungs is assessed on the posterior chest?
All parts of the lower lobes
Which finding would indicate possible vitamin C deficiency?
Bleeding gums
About which condition would the nurse educate the patient wanting a tattoo?
Non-Tuberculous Mycobacterial Infection
What describes the pericardium?
Tough, fibrous double walled sac surrounding the heart
Which score would alert the nurse to intimate partner violence (IPV) when using the Hurt, Insult, Threaten, and Scream (HITS) screening tool?
11
Which term would the nurse use to document a rug burn found on a child’s back?
Friction Abrasion
Which finding is expected during a breast assessment of an older adult patient?
The breast decrease in size and elasticity
In regards to the mnemonic ABCDEF, which aspect would be represented by the “D”?
Diameter
Which description of semilunar valves is correct?
Lie between the ventricles and the arteries
The patient answered yes to the questions about tolerance and eye-opener and no to worry, amnesio, and kut down. Which score would be recorded using the Tolerance, Worry, Eye-Opener, Amnesia, and Kut down (TWEAK) questionnaire?
3
When a patient is devoid of melanin pigment in patchy areas of the skin on the face, neck, and, feet, and body folds, which condition would the nurse document?
Vitiligo
which term would the nurse document to describe individual lesions that remain separate from each other?
Discrete
Which assessment finding is related to erythema in a dark-skinned patient diagnosed with polycythemia?
Reddish lips
Which type of primary lesion would be superficial in the epidermis more than 1 cm in diameter and rupture easily?
Bulla
Which term would the nurse use to describe the white cheesy substance on the neonate’s body?
Vernix caseosa
When a child diagnosed with impetigo presents with vesicles having an erythematous base, for which additional assessment finding wold the nurse monitor?
Thick, honey-colored crusts
Which skin finding present in a newborn would alert the nurse to fetal distress?
Greenish-brown discoloration of the nails and cord
When would the nurse begin to assess a newborn for physiologic jaundice?
Around the 4th day of life
Which physiologic mechanism causes the first heart sound?
Closing of the mitral valve
Which heart rate would be found in a 4 month old infant with bradycardia?
50 bpm
Which heart sound occurs because of the closure of the semilunar valves?
S2 Second heart sound
Which description of chordae tendineae is correct
Collagenous fibers that anchor the leaflets of the atrioventricular valves
Which section of the electrocardioram (ECG) indicates atrial depolarization?
P wave
How would the nurse document a loud heart murmur with a palpable thrill?
4/6
Which possible cause would be associated with a scaphoid=shaped abdomen in a 4-year-old patient?
dehydration
Which medium to low-pitch systolic sound would the nurse hear when auscultating between the xiphoid process and the umbilicus?
Bruits
Which observation would the nurse associate with abdominal pain related to peritonitis?
absolute stillness
Which specific abdominal assessment would the nurse perform to confirm rebound tenderness?
Blumberg sign
Which condition would cause the stool to be gray in color?
Presence of hepatitis
To determine the most frequent method of acquisition, which question would the nurse ask a patient who abuses pain relievers?
“Did you get these from a friend or relative?”
Which initial score on the Clinical Institute Withdrawal Assessment (CIWA) would warrant the nurse measuring vital signs every hour for 8 hours?
greater than or equal to 8
Which score on the Clinical Institue Withdrawal Assessment (CIWA) would cause the nurse to follow the prescribed scheduled medication for the treatment of alcohol withdrawal?
Equal to or greater than 15
Which score on the Alcohol Use Disorders Identification Test (AUDIT) would alert the nurse to the possibility of hazardous alcohol consumption in an adolescent?
Equal to or greater than 4
Which behavioral change would the nurse observe in a patient abusing benzodiazepines?
Sexual aggressiveness
When using the Alcohol Use Disorders Identification Test-C (AUDIT-C) the nurse would assign a score of 2 to which category of alcohol abuse?
Low-risk drinking
Which condition would be associated with sympathetic system stimulation because of alcohol intake?
Vasoconstriction
For which drug intoxication would the nurse assess in a patient who has dilated pupils, act superior and continuously scans the surroundings for threats
Cocaine
Which method would be appropriate when examining large, pendulous breasts?
Leaning forward while the nurse supports the forearms
Which condition is commonly found in the tail of spence?
Breast Cancer
Which structure drains more than 75% of the lymph from the breasts?
Ipsilateral axillary nodes
Which finding would be identified as abnormal in a patient’s breast assessment?
Localized redness with heat
Which finding would indicate signs of malnutrition for a patient who recently immigrated from a developing country?
Dental caries
Which beverage would the nurse avoid providing a patient of Orthodox Judaism faith who received beed at lunch?
Milk
Which nutrient would be increased in the diet of a patient who has dull dry sparse hair and eczema?
Linoleic acid
Which nutrient deficiency would cause red conjunctivae in the patient?
Riboflavin (Vit B2)
Decreased tactile fremitus is consistent with which diagnosis?
Pleural Effusion
The nurse is aware that structures at which depth are able to be assessed with percussion?
5-7 cm
