Midterm

Question 1

The nurse is preparing a poster on self-breast examination and labeling the anatomical structures of the breast. Which location will the nurse use to identify the tail of Spence?

Answer 1

B

Question 2

A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Answer 2

Carotid

Question 3

On auscultation of valvular sounds over precordium, what area is auscultated at the second intercostal space at the right sternal border?

Answer 3

Aortic

Question 4

During a cardiac examination, where can the nurse best heat the S2 heart sound?

Answer 4

At the base of the heart

Question 5

At which location would the nurse place auscultate the tricuspid valve?

Answer 5

At the left fourth intercostal space

Question 6

A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening?

Answer 6

Pre-adolescents/adolescent

Question 7

A nurse is assessing a client’s cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II

Answer 7

Ask the client to read a Snellen chart

Question 8

The client complains of sinus pressure and headache. What type of percussion does the nurse anticipate using during the exam?

Answer 8

Direct

Question 9

The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the client’s plan of care, which nursing diagnosis is most applicable?

Answer 9

Knowledge deficit

Question 10

The nurse assesses a client’s vision to be a 20/80. The client asks for an explanation of the numbers. Which of the following would be a correct explanation for the nurse to say to the client?

Answer 10

You see at 20 feet what a person with normal vision sees at 80 feet

Question 11

While shining the penlight into the eyes of a client check pupil constriction, the nurse notes the client’s unilluminated pupil constricts slightly slower than the illuminated pupil. What does this finding indicate?

Answer 11

This is a normal finding

Question 12

While inspecting the tympanic membrane, the nurse notes a pearly gray and shiny appearance. What would this finding indicate?

Answer 12

Intact tympanic membrane.

Question 13

Which statement describes a Rinne test that is within normal limits?

Answer 13

Air conduction is greater than bone conduction.

Question 14

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

Answer 14

The P wave falls before the QRS complex.

Question 15

A nurse is instructing a group of nursing students in the priorities of care in performing an integrumentary assessment of their clients. Which of the following findings should the students recognize as requiring immediate intervention?

Answer 15

Cyanosis

Question 16

A nurse is assessing edema of a client’s lower extremities and notes an indentation of 4mm. How should the nurse document the degree of pitting edema?

Answer 16

2+

Question 17

How should the nurse document a weak/thready pulse?

Answer 17

+1

Question 18

During a cardiovascular assessment, how should the nurse describe a “thrill”?

Answer 18

A vibration that is palpable.

Question 19

What should the nurse do when assessing the carotid arteries of an older client with cardiovascular disease?

Answer 19

Listen with the bell of the stethoscope to assess for bruits.

Question 20

The nursing student is asked to demonstrate the Allen test on a fellow student. Which of the following best describes the Allen test?

Answer 20

Test used to determine patency of the radial and ulnar arteries.

Question 21

A student nurse is reviewing telemetry strips in preparation for an upcoming test. What does the QRS in the ECG represent?

Answer 21

Ventricular depolarization

Question 22

The male client weighs 280 pounds. What is the best technique on auscultation of the heart in an obese client?

Answer 22

Place client in the left lateral position and listen at the apex.

Question 23

During the cardiac assessment, the nurse finds a client has jugular vein distention. What does this mean to the nurse?

Answer 23

The client could have fluid overload.

Question 24

The nurse is auscultating the temporal artery and hears a soft blowing sound. How would the nurse would correctly document this finding?

Answer 24

A bruit.

Question 25

The nurse is performing a cardiac assessment and needs to locate the point of maximal impulse. Which location would the nurse choose to locate this?

Answer 25

Fifth intercostal space, midclavicular line

Question 26

The nurse is documenting an ulcer on the lateral aspect of the client’s right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. Which other assessment data would be useful to determine the origin of this client’s ulcer?

Answer 26

Peripheral pulses.

Question 27

The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery. Which test may be used to help determine the patency of this artery?

Answer 27

Allen test.

Question 28

A nurse is assessing a client’s peripheral circulation. Which location should the nurse palpate to assess the posterior tibial pulse?

Answer 28

C

Question 29

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or “Hot Spots,” are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Answer 29

Left pedal pulse

Question 30

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was

Answer 30

hoarseness

Question 31

A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses?

Answer 31

Malignant melanoma

Question 32

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Answer 32

Cheyne-Stokes respirations

Question 33

A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?

Answer 33

Pulse oximetry changed from 98% to 94%

Question 34

A nurse in a provider’s office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish-brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions?

Answer 34

Kaposi’s sarcoma

Question 35

A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make?

Answer 35

“These organs support immunity.”

Question 36

The client has an enlarged lymph underneath his jaw. How should the nurse accurately document this finding?

Answer 36

Submandibular lymph node enlarged.

Question 37

The client has an enlarged lymph node in front of the right ear. Which phrase will the nurse use to document this finding in the medical record?

Answer 37

Right-sided preauricular lymph node enlarged.

Question 38

A client is reporting itching to the ear and fever. The client presents with swelling and redness of the auricle and ear canal with scant drainage is present. Which condition would the nurse suspect?

Answer 38

Otitis externa.

Question 39

After a client had a stroke, the right side of his face is drooping. The nurse would also suspect which additional findings?

Answer 39

Dysphagia.

Question 40

A student arrives at the university clinic reporting asthma-like symptoms. Which lung sounds would the nurse most likely hear upon auscultation?

Answer 40

High-pitched, continuous sounds.

Question 41

The nurse is caring for a client who is a long-time smoker and notes clubbing of the fingers. Which technique should the nurse use to validate this assessment?

Answer 41

Place two of the same fingers from each hand together.

Question 42

During an elderly client’s physical exam, the nurse notes his fingernails are spongy, round, and wide with the angle greater than 170 degrees. How would the nurse document this finding?

Answer 42

Clubbing.

Question 43

The nurse performing a respiratory assessment on her client and hears rhonchi in bilateral lobes. Which is the best description for this adventitious sound?

Answer 43

Low pitched, continuous, snoring or rattling.

Question 44

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition?

Answer 44

Hypoxemia

Question 45

A nurse is assessing a client who has COPD. The nurse should expect the client’s chest to be which of the following shapes?

Answer 45

Barrel

Question 46

The nurse is interviewing a client and notes that the left eyelid is drooping. How would the nurse would correctly chart this condition?

Answer 46

Ptosis

Question 47

During an eye assessment, a young adult client reports difficulty seeing items within close range. This assessment data is consistent with which term?

Answer 47

Hyperopia.

Question 48

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

Answer 48

indicates turbulent blood flow through a valve.

Question 49

When preforming a breast exam, which abnormalities might indicate cancer? Select all that apply.

Answer 49

Dimpling;Change in skin color;Nipple discharge in a non-lactating woman

Question 50

The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. Which term is the most appropriate for the nurse to use when documenting this finding in the medical record?

Answer 50

Vesicle.

Question 51

In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. What is the reason for this specific assessment?

Answer 51

Location of most breast tumors.

Question 52

A nurse is assessing a client’s cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

Answer 52

The left second intercostal space

Question 53

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?

Answer 53

Atrial depolarization

Question 54

A nurse is interpreting a client’s ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

Answer 54

QT interval

Question 54

A nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect?

Answer 54

Painful lesions following a nerve pathway

Question 55

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Answer 55

Skin tenting present

Question 56

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

Answer 56

Leg pain at rest

Question 57

A nurse is auscultating a client’s heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

Answer 57

The fourth heart sound S4