sonyasabrah – Flashcards
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When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?
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Bronchitis
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A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next?
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Ask about any medications being used for hypertension.
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While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?
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Emphysema
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A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding?
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Hypoventilation
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A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?
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Asthma
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Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?
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Have the client cough, then listen again
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A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honour student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms?
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Spontaneous pneumothorax
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A client presents to the health care facility with a two (2) week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a one (1) pack per day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?
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Impaired Gas Exchange
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A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?
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Severe brain damage
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Which of the following muscles is primarily responsible for thoracic cavity enlargement?
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Diaphragm
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A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
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Chronic obstructive pulmonary disease (COPD)
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A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?
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Opiates, which may cause hypoventilation
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While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document this as which of the following?
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Bronchial breath sounds
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A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
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"Are you taking any medications on a regular basis?"
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The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination? (Select all that apply.)
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• Older adult attending adult day care • Adult patient caring for children under age 5 • Adult patient with chronic obstructive pulmonary disease
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When percussing the posterior lung fields, which of the following findings is expected?
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Resonance over all lung fields
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A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
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a foreign body obstruction
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When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?
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One deep inspiration and expiration through the open mouth
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A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?
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A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min
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The nurse is preparing to auscultate the breaths sounds of a client's anterior chest. The nurse notes that the client's chest has a large amount of hair on it. Which of the following would the nurse do?
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Have the client put his T-shirt back on and auscultate through the shirt
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Which is true of a third heart sound (S3)?
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It is caused by rapid deceleration of blood against the ventricular wall.
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How should a nurse assess a client for pulse rate deficit?
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Assess for a difference between the apical and radial pulse
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The nurse positions the client for auscultation of heart sounds. What does the nurse do first?
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Clean the stethoscope
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In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?
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left midclavicular line at the fifth intercostal space
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The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.
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true
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A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?
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Smoking increases the heart's workload and contributes to atherosclerosis.
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The nurse is palpating the apical impulse in a client with heart disease and finds that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?
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Aortic stenosis, with pressure overload of the left ventricle
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The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate?
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Palpate each artery individually to compare
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When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?
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s1
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After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following?
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Ventricles
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A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?
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Parkinson's disease
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A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
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tension
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Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?
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Chronic obstructive pulmonary disease
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Which of the following occurs in respiratory distress?
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Skin between the ribs moves inward with inspiration.
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A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?
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Vertebral line
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A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?
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Range of motion of the neck
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The nurse is performing a cardiac examination of a client with shortness of breath and palpitations. The nurse listens to the heart with the client sitting upright, then has him change to a supine position, and finally has him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?
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Mitral
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A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source?
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cardiac
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A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?
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Inflammation of the pericardial sac
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When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
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The underlying bones
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Which assessment of the tongue should a nurse recognize as abnormal?
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Red with loss of papillae
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Which of the following manifestations is the most problematic for the patient diagnosed with Meniere's disese?
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Vertigo
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When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)
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a) notched border b) diameter great than 6 cm c) asymmetry
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A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?
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Torus palatinus
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During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?
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Coarse crackles
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Question: The nurse assists and educates clients about the structure and function of the sensory system. The nurse is showing the client the path taken by sound waves to reach the brain. The nurse dropped the note cards with the correct sequence on the floor. The sequence of steps is scrambled and need to be placed in the correct order. Which is the correct order of the steps in the path taken by sound waves to the brain?
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1. sound waves enter though the ear's external auditory canal and strike the tympanic membrane. 2. The tympanic membrane vibrates at various speeds in response to various pitches of sounds. 3. The ossicles within the middle ear act as a moveable bridge to transmit these vibrations to the oval window, which amplifies the sound waves. 4. The stapes vibrates against the membrane, setting the fluid of the cochlea in motion, which in turn passes on to the hair like nerve ending in the organ of Corti. 5. The stimuli in the organ of Corti are sent to the vestibulocochlear nerve and to the temporal lobe in the cerebral cortex, where the sounds are interpreted.
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The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?
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Decreased serum calcium level on review of labwork.
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A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:
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whisper test
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While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse documents this finding as which of the following?
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Petechiae
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What part of the eye receives and transmits visual stimuli to the brain for processing?
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retina
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A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?
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Glaucoma
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Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?
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Knife-like pain that worsens on inspiration
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A nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?
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"Are you experiencing any tooth pain?"
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While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following?
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Pericardial friction rub
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A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following would the nurse do next?
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Perform a random blood sugar test.
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Where are the heart and great vessels located in the human body?
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The mediastinum, between the lungs above the diaphragm
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A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?
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"Have you taken any antibiotics in the past few weeks?"
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During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?
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2
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The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient?
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Primary
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While completing the cardiovascular system health history, a patient tells the nurse about using four pillows at night to sleep. The nurse will use this information to further assess which area?
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Shortness of breath
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A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the
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focused
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The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination? (Select all that apply.)
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Older adult attending adult day care • Adult patient caring for children under age 5 • Adult patient with chronic obstructive pulmonary disease
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A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
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Observe for the use of accessory muscles
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What is the most important physical sign of acute pericarditis?
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Pericardial friction rub
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The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?
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The pattern is expected with this condition
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Which of the following is true regarding self breast examination?
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A high proportion of breast masses are detected by self breast examination.
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A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?
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Lymphadenopathy of infectious origin
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A 56-year-old woman comes to the clinic reporting that her left breast looks unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-breast examinations so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and drinks three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy, but her father died of prostate cancer. Examination shows a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating towards the lateral side. On palpation the nipple feels thickened. Lateral to the areola is a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast examination and axilla are unremarkable. What visible skin change of the breast does she have?
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Nipple retraction
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When should a woman conduct self breast examination with respect to her menses?
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5 to 7 days following her menses
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Which is true of women who have had a unilateral mastectomy?
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They should be examined carefully along the surgical scar for masses.
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Which of the following assessment findings is most likely benign on breast examination?
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One breast larger than the other
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When palpating the female breast for masses, the nurse distinguishes which of the following characteristics as a potentially cancerous mass?
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Single, firm, fixed nodule
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A 26-year-old female presents to the health care clinic for a yearly pap & physical exam. She tells the nurse that she has felt a few tender areas in the left breast that are only occasionally palpable. She drinks about 3 cups of coffee daily and an occasional soft drink with caffeine. Family history reveals a maternal aunt with breast cancer at age 75 years. Which nursing diagnosis can be confirmed from this data?
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Ineffective Health Maintenance
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The nurse is performing a breast exam. Which area would be most important for the nurse to assess?
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Upper outer quadrant
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A middle-aged female tells the nurse that she is concerned because her breasts are not as firm as they used to be. What is an appropriate response by the nurse?
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"Firmness of the breasts decrease with lower estrogen levels"
