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After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:

Objective

The nurse is performing a general survey. Which action is a component of the general survey?

Observing the patient's body stature and nutritional status

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

The presence of kyphosis and flexion in the knees and hips

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:

The diurnal cycle.

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that:

unexplained weight loss often accompanies short-term illnesses.

When assessing a patient's lungs, the nurse recalls that the left lung:

consists of two lobes

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

a normal finding in a healthy adult.

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the:

sternal angle

The primary muscles of respiration include the:

diaphragm and intercostals.

The nurse is auscultating the chest in an adult. Which technique is correct?

Use the diaphragm of the stethoscope held firmly against the chest.

When inspecting the anterior chest of an adult, the nurse should include which assessment?

The shape and configuration of the chest wall.

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult?

The lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:

tuberculosis

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?

Pulmonary edema

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

muffled voice sounds and symmetrical tactile fremitus

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

increased density of lung tissue

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.

side-to-side

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:

vesicular breath sounds and are normal in that location.

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal:

Dullness

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:

decreased mobility of the thorax

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

When part of the lung is obstructed or collapsed

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?

Pulmonary consolidation

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:

expected near the major airways.

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?

Wheezes

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to:

the eccrine glands

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

Melanocytes

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:

the woman could be at increased risk for infection and lesions because of her chronic disease

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:

excess blood in the dilated superficial capillaries

A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? He probably has:

seborrheic keratoses, which do not become cancerous.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:

papule

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?

Clubbing of the nails

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor?

An increased loss of elastin and a decrease in subcutaneous fat in the elderly

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:

xerosis

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:

caused by the complete absence of melanin pigment.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding?

Color variation

An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?

Dry mucous membranes and cracked lips

A patient has had a "terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:

lichenification

The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions?

Severe dehydration

The nurse is assessing for inflammation in a dark-skinned person. Which is the best technique?

Palpate the skin for edema and increased warmth.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. The nurse would begin the examination suspecting:

tinea capitis

The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick?

The atria contract toward the end of diastole and push the remaining blood into the ventricles.

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

aortic and pulmonic

The component of the conduction system referred to as the pacemaker of the heart is the:

sinoatrial (SA) node.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

elevated pressure related to heart failure.

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be:

"Do you have any history of problems with your heart?"

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

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

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

Fifth left intercostal space at the midclavicular line

When listening to heart sounds, the nurse knows that S1:

coincides with the carotid artery pulse

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

bell at the apex with the patient in the left lateral position

The direction of blood flow through the heart is best described by which of these?

Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle

The electrical stimulus of the cardiac cycle follows which sequence?

SA node AV node bundle of His bundle branches

The nurse knows that normal splitting of the second heart sound is associated with:

inspiration

During a cardiovascular assessment, the nurse knows that a "thrill" is

a vibration that is palpable

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

African-Americans

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?

Lateral to the extensor tendon of the great toe

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?

Person who has been on bed rest for 4 days

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?

Examine the patient's lower arm and hand, and check for the presence of infection or lesions

The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next?

Consider this a delayed capillary refill time and investigate further.

A patient has a positive Homans' sign. The nurse knows that a positive Homans' sign may indicate:

deep vein thrombosis

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

A brownish discoloration to the skin of the lower leg

When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:

bruits occur with turbulent blood flow, indicating partial occlusion

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:

nonpitting, hard edema occurs with lymphatic obstruction

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:

paradoxus

The nurse is preparing to perform a manual compression test on a patient. Which of these statements is true about this procedure?

A palpable wave transmission occurs when the valves are incompetent.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing:

problems related to arterial insufficiency.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?

Enlarged and tender inguinal nodes

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

dysphagia

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

An enlarged spleen should not be palpated because it can rupture easily

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:

normal abdominal aortic pulsations

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

"It prevents distortion of bowel sounds that might occur after percussion and palpation."

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

hyperactive bowel sounds

During an abdominal assessment, the nurse would consider which of these findings as normal?

During an abdominal assessment, the nurse would consider which of these findings as normal?

A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of:

kidney inflammation

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

Percuss and palpate the midline area above the suprapubic bone.

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

dysphagia

The functional units of the musculoskeletal system are the

joints

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the:

Glenohumeral joint.

A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains:

of sharp pain that increases with movement

The nurse should use which test to check for large amounts of fluid around the patella?

Ballottement

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

proximal to distal.

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of:

circumduction

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?

Flexion and extension

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

Crepitation

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to:

hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

swelling from fluid in the suprapatellar pouch

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?

5

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

adduction.

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:

bone marrow

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

of the shortening of the vertebral column.

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:

loss of bone density

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:

medial and lateral epicondyle

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?

Reflexes will be normal

Frontal lobe of the cerebral cortex mediates the following function

Intellectual functions and personality

The area of the brain that controls temperature, appetite, sex drive and sleep center is

Hypothalamus

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?

Motor component of VII

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):

positive Romberg sign

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurse's next response should be to:

ask the patient to lock her fingers and "pull."

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