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health assessment > exam 2 > Flashcards

exam 2 Flashcards

1
Q

a palpable vibration increased with lobar pneumonia is also known as:

A

fremitus

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2
Q

your patient is exhibiting rapid shallow breathing, with a respiratory rate >24 respirations per minute. which of the following conditions are they experiencing?

A

tachypnea

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3
Q

which of the following terms is used to describe a decreased level of oxygen (O2) in the blood?

A

hypoxemia

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4
Q

upon receiving the patient’s lab results, the nurse notes that patient has increased level of carbon dioxide in the blood. which of the following conditions would the patient be experiencing?

A

hypercapnia

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5
Q

the nurse is auscultating a patient’s lungs and hears discontinuous, high-pitched m, short, popping sounds heard during inspiration, and not cleared by coughing. these are described as:

A

crackles

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6
Q

the nurse is assessing a patient’s lungs by using the percussion technique. which sound would the nurse expect to hear over healthy lung tissue?

A

resonance

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7
Q

a clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is:

A

pursed lip breathing

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8
Q

which of the following are functions of the respiratory system? (select all that apply)

A
  • supplying oxygen to the body for energy production
  • removing carbon dioxide as a waste product
  • maintaining homeostasis (acid-base balance) of arterial blood
  • maintaining heat exchange
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9
Q

stridor is a high pitched, inspiration crowing sound commonly associated with:

A

upper airway obstruction

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10
Q

which of the following correctly expresses the relationship to the lives of the lungs and their anatomic position?

A

lower lobes-posterior chest

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11
Q

the function of the trachea and bronchi is to:

A

transport gases between the environment and the lung parenchyma

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12
Q

which of the following configurations is an exaggerated posterior curvature of the thoracic spine that is associated with agin and physical fitness?

A

kyphosis

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13
Q

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 comparison

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14
Q

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

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15
Q

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

chest pain is worse on deep inspiration and dyspnea

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16
Q

freshly oxygenated blood enters the heart through the ____, and is pumped out to the body through the _____.

A

left atrium; aorta

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17
Q

when listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

A

aortic and pulmonic

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18
Q

the nurse is asking the client for subjective data before performing a cardiac and great vessel assessment. which of the following should the nurse ask? select all that apply

A
  • do you ever have any dyspnea?
  • have you noticed any edema?
  • have you had any chest pain?
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19
Q

the nurse is teaching the client about health promotion or the cardiovascular system. which of the following statements would indicate a need for further teaching ?

A

“even though my dad had a heart attach, i don’t need to get screened for heart issues earlier than anyone else. “

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20
Q

how should the nurse document mild, slight putting edema on the ankles of a heart failure client?

A

1+

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21
Q

the nurse is educating the client about risk factors for cardiovascular disease. which of the following risk factors for cardiovascular disease are modifiable? select all that apply.

A

smoking
abnormal lipids
hypertension
diabetes

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22
Q

which of the following is and appropriate position to have the client assume when auscultating for extra heart sounds or murmurs?

A

roll towards the left side.

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23
Q

which statement is true regarding the arterial system?

A

the arterial system is a high pressure system

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24
Q

when assessing a client the nurse is unable to palpate the left dorsal is pedis pulse. what should the nurse do first?

A

find a doppler and see if the pulse can be heard through ultrasound

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25
Q

a 67 year old client states that he recently began to have calf 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 client is most likely experiencing:

A

intermittent claudication

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26
Q

the nurse is preparing to perform a modified allen test. which is an appropriate reason for this test?

A

to evaluate the adequacy of collateral circulation before cannulating the radial artery

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27
Q

in assessing the carotid arteries of an older client with cardiovascular disease, the nurse would:

A

listen with the bell of the stethoscope to assess for bruits

28
Q

when auscultating over a client’s femoral arteries, the nurse notices the presence of a bruit on the left side. the nurse knows that bruits:

A

occur with turbulent blood flow, indicating partial occlusion

29
Q

the nurse is performing an assessment on a client. which of the following should the nurse ask to obtain subject data related to the client’s gastrointestinal system?

A
  • have you experienced any changes in bowel habits?

- what medications are you taking?

30
Q

the nurse is caring for a client who reports having abdominal pain. after inspecting the client’s abdomen, the nurse would be correct in performing what assessment technique?

A

auscultation

31
Q

the nurse is teaching a client about health promotion of the gastrointestinal system. which of the following statements would indicate a need for further teaching ?

A

“the amount of alcohol i have should not affect my health if i dilute it with water. “

32
Q

a nurse is performing an assessment on a client. which of the following statements demonstrates her understanding of the rationale for correct sequencing for an abdominal assessment?

A

“it is impotent to sequence the exam to avoid distorting the client’s bowel sounds. “

33
Q

a nurse is performing an abdominal assessment. the nurse correctly observed the following assessment findings when inspecting the client’s abdomen. select all that apply

A
  • contour and symmetry
  • appearance of umbilicus
  • skin color
  • demeanor
34
Q

during and additional assessment, the nurse is unable to hear bowel sounds in a client’s abdomen. the nurse understands that before reporting this finding as “absent bowel sounds” it is important to listen for at least ______ in each quadrant.

A

5 minutes

35
Q

a nurse is performing an assessment on a client who reports abdominal pain. which of the following actions should the nurse implement to promote relaxation of the client’s abdomen during the assessment?

A
  • position the client supine, with the knees bent

- distract the client

36
Q

the nurse is aware that one change that may occur in the gastrointestinal system of an again client is:

A

decreased gastric acid secretion

37
Q

the nurse is performing percussion by tapping on a client’s abdomen in the left upper quadrant (spleen) and right upper quadrant (liver). which of the following would be an expected assessment finding in these two areas of the GI system?

A

dullness

38
Q

during an assessment, the nurse notices that the client’s umbilicus is enlarged and everted. the nurse recognizes this as:

A

abnormal: may be an umbilical hernia

39
Q

the nurse is preparing to examine a client who reports right lower abdominal pain. the nurse’s priority would be to:

A

palpate the tender area last

40
Q

the nurse is assessing a client’s abdomen. she places the diaphragm of the stethoscope in the area where bowel sounds are prominent which is:

A

right lower quadrant (RLQ)

41
Q

in performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast tissue is especially important. the reason for this is that the upper put quadrant is:

A

tail of spence. the location of most breast tumors

42
Q

the nurse is teaching a client about risk factors for breast cancer. she correctly includes which of the following risk factors?

A

menstruation before age 12 or menopause after age 55

high fat diet

43
Q

during a breast health assessment, the client states that she has noticed pain in her left breast. an appropriate response to this by the nurse would be:

A

“i would like some more information about the pain in your left breast.”

44
Q

during an annual physical examination, a 43 year old client 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

45
Q

during an examination of a client, the nurse notices that her left breast is slightly larger than her right breast. which of these statements is the about this finding?

A

asymmetry is not unusual, but the nurse should verify that this change is not now

46
Q

during the physical examination, the nurse notices that the client has an inverted left nipple. which statement regarding this is most accurate?

A

the nurse should determine whether the inversion is a recent change

47
Q

the nurse is assessing a client’s breasts during an examination. which of these positions is most likely to make significant lumps more distinct during breast palpation by displaying the breast against the chest wall ?

A

supine with the arms raised over her head

48
Q

a nurse is performing a client assessment. which of these clinical situations, if noted, should the nurse consider to be outside normal limits?

A

the client has two pregnancies. her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipple.

49
Q

the nurse is educating a client on breast self-examination (BSE). which of these statements by the client indicates understanding of the proper BSE techniques

A

“the best time to perform the BSE is 4 to 7 days after the first day of my menstrual cycle.”

50
Q

the nurse is education a 55 year old client on breast self-examination (BSE). which of these statements by the client indicates understanding of the information provided? “ the best time for postmenopausal women to perform BSEs is ___________”

A

“on the same day every month.”

51
Q

a client comes to the clinic with what he calls a “horrible problem.” he tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. which of the following statements is true about breast cancer?

A

gynecomastia is a benign growth of the breast tissue

52
Q

the nurse is palpating a client’s breasts during a seated examination. she notes the client has large pendulous breasts. what is the most appropriate course of action for the nurse to take?

A

use the biannual technique to perform the assessment

53
Q

during a client examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?

A

using gentle pressure, palpate with both hands to compare the two sides

54
Q

the nurse is palpating a client’s temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the travis. which of the following would be a normal finding ?

A

nontender to palpation

55
Q

which of the following subjective data would the nurse want to collect for the client when performing a head, face and neck exam? select all that apply.

A
  • if they have unusually frequent or severe headaches
  • if they have any dizziness
  • if they have any neck pain
  • if they have any history of neck injury or surgery
56
Q

a client’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. a bruit is a ______ sounds that is heard best with the _____of the stethoscope.

A

soft, whooshing, pulsatile; bell

57
Q

the nurse is assessing the client’s trachea. which of the following would be a normal finding?

A

the trachea rising to midline when the client swallows

58
Q

the nurse is assessing a client’s neck ROM. The nurse would correctly expect the client to be able to perform which movement with the neck?

A

flexion, hyperextension, rotation and lateral bending

59
Q

the nurse is performing the diagnostic positions test (six cardinal fields of gaze) to check the extra ocular eye muscles. the nurse knows that a healthy finding would be:

A

there is parallel tracking of the object with both eyes

60
Q

when assessing the pupillary light reflex, the nurse should use which technique?

A

shine a light across the pupil from the side and observe for direct and consensual pupillary construction

61
Q

when performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o’clock in each eye. the nurse should:

A

consider this a normal finding

62
Q

the nurse is assessing the pupils of a client with a pen light. which finding would be considered normal?

A

both pupils constrict in response to light

63
Q

in using the ophthalmoscope to assess a client’s eyes, the nurse notices a red glow in the pupils. on the basis of this finding, the nurse would:

A

consider this a normal reflection of the ophthalmoscope light off the inner retina

64
Q

the nurse is charting on a client’s eye assessment and noted PERRLA. what dies this stand for?

A

pupil, equal, round , react to light, accommodation

65
Q

the nurse is assessing the client’s pupillary response to light. the nurse moved the pen light in from the side of the client’s face into the right eye. both the right eye and left pupil constrict. how would these reflexes be described?

A

right eye direct response, left eye consensual response.

health assessment (4 decks)

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