question

The nurse auscultates a patient's lung fields and identifies a pleural friction rub. A pleural friction rub can BEST be described as....

answer

grating sound or vibration heard during inspiration and expiration EXPLANATION: caused by inflamed pleura; does not clear by coughing

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Rales

answer

gurgling sounds commonly heard on inspiration

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Wheezes

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squeaky sounds heard during inspiration and expiration

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Bronchophony

answer

loud transmission of voice sounds caused by consolidation of lung

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Adventitious Breath Sounds

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breath sounds not head normally including crackles, wheezes, rales, or stridor; may occur with either or both inspirations and expirations

question

When performing a physical assessment, the home health nurse notes that the eyes of the client involuntarily move rapidly from side to side. Which of the following term should the nurse in charting to describe this observation?

answer

Nystagmus

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Strabismus

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the involuntary drifting of one eye out of alignment with the other eye; "lazy eye"; may be inherited or paralytic, the latter from causes such as injury to the eye or brain, tumor or infection

question

Photophobia

answer

light intolerance; seen in various conjunctival disorders and conditions such as rubella (measles)

question

Ptosis

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drooping of the upper eyelid; may be congenital or acquired weakness or paralysis

question

Which sound does the nurse expect to hear when percussing the lungs of a client diagnosed with emphysema?

answer

Hyperresonance

question

Dullness

answer

medium, thud-like muffled, medium-pitched sound of short to moderate duration heard over dense fluid-filled tissue such as the liver, spleen, pleural effusion; percussing diaphragm will also yield a dull sound

question

Tympany

answer

loud, musical or drum-like, high-pitched sound of moderate or long duration heard with enclosed air-filled structures such as intestines

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Hyperresonance

answer

very loud, booming, low-pitched sound of long duration heard in conditions of over-inflated air-filled tissue

question

Flatness

answer

is very soft, flat, high-pitched sound of short duration heard over very dense tissue such as bone, muscle

question

When assessing the abdomen, the nurse should place the patient in which of the following positions?

answer

supine with knees flexed

question

supine position

answer

flat on back; position to avoid hip flexion

question

Side lateral position

answer

allows for drainage of oral secretions

question

Sims' position

answer

lying on side with knees bent; allows for drainage of oral secretions

question

When assessing the client for tactile fremitus, which part of the hand should the nurse use?

answer

ulnar and palmar surface of hand

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fingertips and fingerpads

answer

used for palpating pulses, lymph nodes, texture, consistency, size, shape, crepitus, these are all areas requiring fine discrimination, and fingertips have concentrations of nerve endings

question

Dorsal surface of hand

answer

used for assessing temperature since the skin is thin and there is nerve density

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Dorsiflexed surface of wrist

answer

the wrist is not used for palpation

question

Which statement describes the correct procedure for the nurse to exam a client's pupil?

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compare the sizes of both pupils and check the reaction to light

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Look for red spots around the pupil's circumference

answer

when examining the fundus of the eye with an opthalmoscope, the examiner first identifies the red reflex, which is a bright orange glow in the pupil

question

examine the pupils with an opthalmoscope

answer

used to examine fundus of eye

question

If a person's visual acuity is tested with a Snellen chart and reported to be 20/60, thee nurse knows that the number 60 indicates which of the following?

answer

the distance at which a person with normal vision can read the chart

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In the mental status examination, the nurse asks the client to compare and contrast similar objects and to interpret proverbs. Which client ability is the nurse assessing?

answer

abstract reasoning

question

Judgement

answer

is assessed by asking what the person would do in a certain realistic situations, such as illness; responses considered normal would reflect sound rationale

question

Insight

answer

assessed during the whole interview by listening to the client describe their current health situation, including symptoms, and evaluating whether the client is perceiving self in a realistic and accurate manner

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Orientation

answer

is assessed by asking the client to state his or her name, the current day, month, year, and time, and the location; commonly referred to as "orientation times 3" or "orientation to time, place, and person" when client response is normal

question

The nurse auscultates a patient's breath sounds. The nurse knows that vesicular sounds will have which of the following characteristics?

answer

soft and low-pitched breezy sounds heard over most of the peripheral lung fields

question

loud, coarse, blowing sound heard over the trachea

answer

describes bronchial breath sounds; normal sounds

question

musical sounds or vibration commonly heard on expiration

answer

describes rhonchi; adventitious sounds caused by fluid or inflammation

question

harsh sounds heard over the mainstem bronchi

answer

describes bronchovesicular sounds; normal sounds

question

The nurse in the outpatient clinic receives a phone call from a patient complaining of a rash. Which of the following actions should the nurse take FIRST?

answer

determine if the patient is taking any new medications

question

ask the patient how he is feeling

answer

nurse is assessing, but not asking specific questions about the rash is better

question

instruct the patient to apply a cream to the rash

answer

don't make recommendations until assessment is complete

question

A child's urine is tested for specific gravity, color, and clarity. Which of the following reports would the nurse consider normal?

answer

1.020, yellow, clear

question

1.035, deep orange, cloudy

answer

indicates concentrated urine; cloudy urine indicates infection

question

1.001, yellow, cloudy

answer

urine very dilute; foamy urine indicates presence of protein

question

After receiving report, the nurse assesses the client who is having Cheyne-Stokes respirations. What is the best description of the breathing pattern the nurse should expect to see?

answer

irregular patterns of rapid waxing and waning breathing alternating with periods of apnea

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Irregular patterns of shallow breathing alternating with periods of apnea

answer

referred to as Biot's respirations; seen in neurologic problems such as meningitis and encephalitis, head trauma, heatstroke

question

The home health nurse assesses capillary refill time on a middle-aged client. Which of the following results is considered to be within the normal range?

answer

1-3 seconds

question

Which of these methods should the nurse use to test the gag reflex?

answer

touch the back of the throat with a cotton-tipped applicator; assessing cranial nerve IX glossopharyngeal

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request that the patient speak

answer

assessing functioning of cranial nerve X (vagus)

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ask the patient stick out the tongue and move it from side to side

answer

assesses functioning of cranial nerve XII (hypoglossal)

question

The clinic nurse performs a neurological assessment on a new patient. When the right leg is tapped for the patellar reflex, there is no movement. Which of the following actions should the nurse take FIRST?

answer

tap the tendon again while the patient is pulling against interlaced, locked fingers

question

Which of the following assessment findings in a young adult patient indicates to the nurse that there is a problem with fluid volume deficit?

answer

tenting of the skin

question

taut, shiny skin

answer

is descriptive of edema or fluid retention or excess

question

warm, smooth, elastic skin

answer

describes normal skin reflecting adequate hydration

question

The nurse tests the pH of the child's urine. The nurse expects which result?

answer

pH 6.0

question

pH 3.4

answer

too acidic; pH affected by diet, medications, infections, acid-base balance, and altered kidney function

question

pH 8.2

answer

too alkaline

question

pH 8.5

answer

too alkaline; if urine specimen stands for several hours, will become alkaline

question

The nurse prepares to conduct a physical assessment on a new client in the assisted living facility. The nurse determines which of the following observations will have the MOST impact on the nursing assessment?

answer

presence of assistive devices for vision and hearing

question

The nurse assesses the cardiac status of a patient and identifies an increased pulse pressure. Pulse pressure can best be described as which of the following?

answer

the difference between systolic and diastolic pressure readings

question

peripheral pulses

answer

are assessed in peripheral vascular disease (PVD) and may be graded from 0 to 4, 0 being no detectable pulse and 4 being strong and bounding pulse

question

Pulse deficit

answer

the difference between apical and radial pulse; may reflect a dysrhythmia

question

cardiac output

answer

the stroke volume multiplied by the heart rate

question

stroke volume

answer

the amount of blood ejected with each heartbeat

question

heart rate

answer

the number of beats per minute

question

The nurse prepares to assess a client's ears and hearing. The nurse should gather which of the following equipment?

answer

a tuning fork and an otoscope

question

tonometer

answer

measures intraocular pressure

question

otoscope

answer

used to visualize the middle ear

question

sphygmomanometer

answer

used to measure blood pressure

question

percussion hammer

answer

used to assess the deep tendon and superficial reflexes

question

stethoscope

answer

used to transmit sound from a patient's body to the nurse's ear

question

The nurse identifies which volume is a typical daily urinary output in the normal adult?

answer

1,500 ml

question

Oliguria

answer

less than 400 ml/24 hours; caused by dehydration, acute injury, increased ADH secretion

question

Polyuria

answer

should be reported to health care provider; found in diabetes and chronic nephritis

question

The medical nurse is placing a pulse oximetry probe on a patient newly admitted for evaluation of a seizure disorder. The patients asks the nurse, "Why do I have to have this thing on me?" Which of the following responses by the nurse is BEST?

answer

"It measures the amount of oxygen circulating in your blood"

question

function of an infusion pump

answer

it enables your IV fluids to run at a nice steady rate

question

aortic area

answer

second intercostal space to the right of the sternum

question

Erb's point

answer

third intercostal space to the left of the sternum; both aortic and pulmonic murmurs may be heard there

question

mitral area/apical pulse

answer

fifth intercostal space at the left midclavicular line; location where the heart sounds can best be heard

question

Tricuspid area

answer

fifth intercostals space to the left of the sternum

question

The nurse knows that the average pulse range for an adult is

answer

60-100 bpm

question

normal pulse rate for newborn

answer

120-140 bpm

question

normal pulse rate for a preschooler

answer

80-140 bpm

question

normal pulse rate for school-aged child

answer

70-115

question

The nurse identifies that which of the following risk factors is MOST likely to contribute to an elevation of patient's blood pressure?

answer

a high-pressure job

question

To assess the pedal pulse, the nurse should palpate in which of the following locations?

answer

the top of the foot

question

Popliteal pulse

answer

the region in the back of the knee

question

femoral pulse

answer

passes beneath the inguinal ligament into the thigh; groin area

question

posterior tibial pulse

answer

the inner side of the ankle below the medial malleolus

question

After demographic data is collected by the nurse about a client during an initial health history interview, which should be the next focal area of assessment?

answer

reason for seeking heathcare now

question

After completing the date collection process of the client's health history interview, which action should the nurse take FIRST?

answer

summarize the highlights of the interview and permit the client to add or clarify information

question

The nurse recognizes the physical assessment should be completed in what order?

answer

Inspection, palpation, percussion, and auscultation

question

Abdomen assessment

answer

inspection, auscultation, percussion, and palpation

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