A serous membrane that lines the abdominal cavity and forms a protective cover for many abdominal structures is the:
The peritoneum is a serous membrane that lines the abdominal cavity and serves as a protective cover.
What part of the small intestine forms a C-shaped curve around the head of the pancreas?
The C-shaped curve around the head of the pancreas is the duodenum, the first 12 inches of the small intestine.
Peristalsis of intestinal contents is under the control of:
A. cognitive processes.
C. the autonomic nervous system.
D. the fluid content of the stomach.
The movement of food and digestive products is regulated by the autonomic nervous system.
The esophagus travels a route from:
A. behind the trachea through the mediastinal cavity.
B. lateral to the trachea through the diaphragm.
C. left of the trachea through the peritoneum.
D. the anterior trachea through the cardiac orifice.
The esophagus lies posteriorly to the trachea, descends through the mediastinal cavity and through the diaphragm, and enters the stomach. The esophagus connects the pharynx to the stomach.
Which of the following organs is part of the alimentary tract?
The term alimentary tract refers to the continuous tract from the mouth to the esophagus, stomach, small intestine, large intestine, and anus.
The most superior part of the stomach is the:
D. pyloric orifice.
The most superior aspect of the stomach is the fundus, followed by the body, and then the most distal part, the pylorus.
Which of the following is true regarding the stomach?
A. It lies in the lower right quadrant of the abdomen.
B. It secretes gastric lipase that serves to digest protein.
C. Very little absorption takes place in the stomach.
D. The stomach produces most of the body's bile.
The stomach has a very small role in the absorption of nutrients. The stomach lies across the upper abdomen, not in the lower right quadrant. The stomach does secrete, but gastric lipase does not digest protein. The stomach does not produce most of the body's bile.
The appendix is an extension of the:
C. small intestine.
D. large intestine.
The appendix is a blind-ended tube connected to the cecum, the site of the beginning of the large intestine, located in the right lower quadrant of the abdomen. It develops embryologically from the cecum.
When palpating the abdomen, you should note whether the liver is enlarged in the:
A. left lower quadrant.
B. midepigastric region.
C. periumbilical area.
D. right upper quadrant.
The liver is located in the right upper quadrant of the abdomen.
One major function of the liver is to:
A. secrete pepsin.
B. emulsify fats.
C. store glycogen.
D. absorb bile.
The liver plays a metabolic role; it converts glucose to glycogen, stores it, and then converts glycogen back to glucose as needed by the body.
The majority of nutrient absorption takes place in the:
B. small intestine.
D. transverse colon.
Most absorption takes place in the small intestine. Very little absorption takes place in the stomach. The cecum and transverse colon are part of the large intestine, and their major function is water resorption
The major function of the large intestine is:
A. water absorption.
B. food digestion.
C. carbohydrate absorption.
D. glucose storage.
The major function of the large intestine is the absorption of water and excretion of solid waste material in the form of stool.
Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the:
The liver is responsible for converting fat-soluble waste to water-soluble materials so that the kidneys can excrete them as well as convert ammonia to urea.
Contraction of the gallbladder propels bile into the:
D. large intestine.
With contraction of the gallbladder, bile is excreted into the duodenum.
Which organs both have an excretion function and function as endocrine glands?
A. Kidney and liver
B. Liver and gallbladder
C. Pancreas and kidney
D. Gallbladder and pancreas
The pancreas excretes pancreatic juices as well as producing insulin and glucagons; the kidneys excrete urine and produce rennin and erythropoietin. Although the kidney excretes urine and functions as an endocrine gland, the gallbladder is an excretory organ that is not considered an endocrine gland. The liver and the gallbladder are excretory organs and are not considered endocrine glands. Although the pancreas excretes pancreatic juices and produces insulin and glucagons, the gallbladder is an excretory organ that is not considered an endocrine gland.
The major occupant of the retroperitoneal space is the:
The kidneys occupy most of the retroperitoneal space, lying behind the abdominal cavity, beside the abdominal aorta. The lungs and bladder lie outside the peritoneum, but not in the retroperitoneal area. The spleen is within the peritoneum.
Mrs. James is 7 months pregnant and states that she has developed a problem with constipation. She eats a well-balanced diet and is usually regular. You should explain that constipation is common during pregnancy due to changes in the colorectal areas, such as:
A. decreased movement through the colon and increased water absorption from stool.
B. increased movement through the colon and increased salt taken from foods.
C. looser anal sphincter and fewer nutrients taken from foods.
D. tighter anal sphincter and less iron eliminated in the stool.
Constipation and flatus are more common during pregnancy because the colon is displaced, peristalsis is decreased, and water absorption is increased. Movement through the colon is decreased during pregnancy. The colon does not absorb nutrients. A tighter sphincter tone is not related to pregnancy.
The most pronounced functional change of the gastrointestinal (GI) tract in older adults is:
A. decreased hydrochloric acid production.
B. increased saliva secretion.
C. decreased bile absorption.
D. decreased motility.
Motility of the intestine is the most pronounced GI change in older adults.
The family history of a patient with diarrhea and abdominal pain should include inquiry about cystic fibrosis because it is:
A. a common genetic disorder.
B. one cause of malabsorption syndrome.
C. a curable condition with medical intervention.
D. the most frequent cause of diarrhea in general practice.
Cystic fibrosis is an uncommon, chronic genetic disorder affecting multiple systems. In the gastrointestinal tract, it causes malabsorption syndrome because of pancreatic lipase deficiency. Steatorrhea and abdominal pain from increased gas production are frequent complaints.
When assessing abdominal pain in a college-age woman, one must include:
A. history of interstate travel.
B. food likes and dislikes.
C. age at completion of toilet training.
D. the first day of the last menstrual period.
Exploring abdominal pain complaints in a young woman can reveal multiple causes related to the menstrual cycle including menstrual pain, ovulation discomfort, and abnormal menses. Asking the patient to tell you the first day of her last menstrual period can help discriminate among these factors. History of international travel and traveler's diarrhea can relate to abdominal pain, but interstate travel usually does not. Food preferences and age at completion of toilet training are not relevant.
Infants born weighing less than 1500 g are at higher risk for:
A. hepatitis A.
B. necrotizing enterocolitis.
C. urinary urgency.
Necrotizing enterocolitis is a gastrointestinal disease that mostly affects premature infants; it involves infection and inflammation that cause destruction of the bowel, and it becomes more apparent after feedings.
Inspection of the abdomen should begin with the patient supine and the examiner:
A. seated on the patient's right.
B. standing at the foot of the table.
C. standing at the patient's left.
D. walking around the table.
Being seated on the patient's right is the preferred initial position because it allows tangential viewing of the abdomen for improved assessment of abdominal contour.
Before performing an abdominal examination, the examiner should:
A. ascertain the patient's HIV status.
B. have the patient empty his or her bladder.
C. don double gloves.
D. completely disrobe the patient.
The patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.
Which structure is located in the hypogastric region of the abdomen?
The hypogastric (pubic) area contains the ileum, the bladder, and the pregnant uterus.
You are completing a general physical examination on Mr. Rock, a 39-year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient:
A. hold his or her breath.
B. sit upright.
C. flex his or her knees.
D. raise his or her head off the pillow.
To help relax the abdominal musculature, it is helpful to place a small pillow under the patient's head and under slightly flexed knees. The other techniques are not helpful because they increase muscle flexion.
Mrs. Little is a 44-year-old patient who presents to the office with abdominal pain and fever. During your examination, you ask the patient to raise her head and shoulders while lying in a prone position. A midline abdominal ridge rises. You chart this observation as a(n):
A. small inguinal hernia.
B. large epigastric hernia.
C. abdominal lipoma.
D. diastasis recti.
A diastasis recti occurs when abdominal contents bulge between two abdominal muscles to form a midline ridge as the head is lifted. It has little clinical significance and most often occurs in women who have had repeated pregnancies and obese patients.
After thorough inspection of the abdomen, the next assessment step is:
D. rectal examination.
Assessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence occurs because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.
Mr. Robins is a 45-year-old man who presents to the emergency department with a complaint of constipation. During auscultation, you note borborygmi sounds. This is associated with:
D. paralytic ileus.
Borborygmi are prolonged loud gurgles that occur with gastroenteritis, early intestinal obstruction, or hunger. Peritonitis and paralytic ileus result in hypoactive bowel sounds. Food satiety does not stimulate growling sounds like hunger does.
Peritonitis produces bowel sounds that are:
C. high pitched.
Hypoactive bowel sounds occur with peritonitis and paralytic ileus.
To correctly document absent bowel sounds, one must listen continuously for:
A. 30 seconds.
B. 1 minute.
C. 3 minutes.
D. 5 minutes.
Absent bowel sounds are confirmed after listening to each quadrant for 5 minutes.
Percussing at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating the:
A. descending aorta.
B. lower liver border.
C. medial border of the spleen.
D. upper right kidney ridge.
Percussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.
When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems?
A. Arterial bruit
B. Gastric rumbling
C. Renal hyperresonance
D. Venous hum
Venous hum is associated with blood flow in venous collaterals found in portal hypertension. Aortic bruit occurs during systole, while a venous hum is a continuous sound and softer than a bruit.
Percussion of the abdomen begins with establishing:
A. liver dullness.
B. spleen dullness.
C. gastric bubble tympany.
D. overall dullness and tympany in all quadrants.
Percussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs.
When percussing a spleen, distorted sounds are most likely caused by:
A. colonic air.
B. distended bladder.
C. empty stomach.
D. solid mass.
Percussion of the spleen is more difficult because percussion tones elicited may be due to other conditions. A full stomach or feces in the intestines can mimic splenic dullness, and a dull tone can be obscured by the louder tympany of colonic air.
Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to:
A. percuss for ascites.
B. assess for rebound tenderness.
C. inspect for ecchymosis of the flank.
D. auscultate for abdominal bruits.
Abdominal pain that radiates to the back could be caused by pancreatitis or a gastric ulcer; gallbladder pain usually radiates to the right or left scapula but not to the back; pancreatitis pain can radiate to the left shoulder or scapula; and nausea and vomiting most often occur with gallbladder, pancreas, or appendix conditions. Pancreatitis is a differential diagnosis for all the symptoms, so begin the examination by inspecting the flanks for Grey Turner sign, an indication of pancreatitis.
To assess for liver enlargement in the obese person, you should:
A. use the hook method.
B. have the patient lean over at the waist.
C. auscultate using the scratch technique.
D. attempt palpation during deep exhalation.
If the abdomen is obese or distended, or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver.
An umbilical assessment in the newborn that is of concern is:
A. a thick cord.
B. umbilical hernia.
C. one umbilical artery and two veins.
D. pulsations superior to the umbilicus.
Expect two arteries and one vein. A single umbilical artery indicates the possibility of congenital anomalies. A thick cord suggests a well-nourished fetus, an umbilical hernia will generally spontaneously close by 2 years, and pulsations to the abdomen in the epigastric area are common.
Failure to pass a meconium stool in the first 24 hours after birth along with abdominal distention are often the first signs of:
A. Meckel diverticulum.
B. cystic fibrosis.
C. biliary atresia.
Meconium ileus is often the first manifestation of cystic fibrosis or Hirschsprung disease.
When palpating the aorta, a prominent lateral pulsation suggests:
A. aortic aneurysm.
B. normal pulsation.
C. renal artery fistula.
D. vena cava varicosity.
Anterior pulsations of the aorta are within normal limits; lateral pulsations suggest an aortic aneurysm.
Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition?
A. Positive psoas sign
B. Positive McBurney sign
C. Consistent right lower quadrant (RLQ) pain
D. Rebound tenderness
A positive psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the RLQ are signs of appendicitis. The absence of pain migration makes appendicitis less likely.
When using the bimanual technique for palpating the abdomen, you should:
A. push down with the bottom hand, with the other hand atop.
B. push down with the top hand, with the other hand atop.
C. place the hands side by side and push equally.
D. place one hand anteriorly and the other hand posteriorly, squeezing the hands together.
The bimanual technique uses one hand on top of the other. Exert pressure with the top hand while concentrating on sensation with the other hand.
A 23-year-old man comes to the urgent care clinic with intense left flank and lower left quadrant pain. One patient response to history of present illness questions that further supports a tentative diagnosis of renal calculi is:
A. "My urine has been a bright yellow."
B. "I have had fever and chills for 2 days."
C. "I also have a headache and neck ache."
D. "My left testicle and shoulder hurt as well."
Renal calculi present with hematuria, intermittent flank pain that radiates to the groin and genitals, and a positive Kehr sign (pain radiating to the left shoulder).
Which of the following is the most useful adjunct to the history of present illness when assessing the quantity and degree of a patient's abdominal pain?
A. Appetite and recall of last meal
B. Family comments about the patient
C. Patient's previous medical record
D. Finding abdominal scars
Inquiring about hunger and eating patterns is an important indicator. It is unlikely that hunger will persist along with acute intra-abdominal infection.
Flatulence, diarrhea, dysuria, and tenderness with abdominal palpation are findings most associated with:
C. ruptured ovarian cyst.
D. splenic rupture.
Only diverticulitis has all of these presenting symptoms.
A 51-year-old woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to:
A. use topical over-the-counter hemorrhoid treatment for 1 week.
B. exercise and eat more fiber.
C. come to the laboratory for a stool guaiac test.
D. eat six small meals a day.
Blood in the stools is an abnormal finding that should never be ignored, even if it can be explained by conditions other than colon cancer. She should have her stool checked for blood now as well as annually because she is older than 50 years.
A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured?
Spleen laceration/rupture is always suspected with abdominal injury because of the spleen's anatomic location. The patient's presenting symptoms confirm this suspicion.
Costovertebral angle tenderness should be assessed whenever you suspect the patient may have:
D. ulcerative colitis.
Pyelonephritis is characterized by flank pain and costovertebral angle tenderness.
The most common congenital anomaly of the gastrointestinal tract is:
A. biliary atresia.
B. pyloric stenosis.
D. Meckel diverticulum.
Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract.
Baby Joe is 6 months old. He has abdominal distention and vomiting and is inconsolable. A sausage-shaped mass is palpable in his right upper quadrant. Joe's lower quadrant feels empty, and a positive Dance sign is noted in his record. Which one of the following conditions is consistent with Baby Joe's symptoms?
B. Kidney stones
C. Meconium ileus
D. Pyloric stenosis
Intussusception refers to the prolapse of one segment of the intestine into another, causing intestinal obstruction. A sausage-shaped mass may be palpated in the right or left upper quadrant, whereas the lower quadrant feels empty (positive Dance sign); it commonly occurs between 3 and 12 months of age.
A mother brings her 2-year-old child for you to assess. The mother feels a lump whenever she fastens the child's diaper. Nephroblastoma is a likely diagnosis for this child when your physical examination of the abdomen reveals a:
A. fixed mass palpated in the hypogastric area.
B. tender, midline abdominal mass.
C. olive-sized mass of the right upper quadrant.
D. nontender, slightly moveable, flank mass.
A Wilms tumor (nephroblastoma) is the most common intra-abdominal tumor of childhood. It presents with hypertension, fever, malaise, and a firm nontender mass deep within the flank that is only slightly movable and is usually unilateral.
In older adults, overflow fecal incontinence is commonly due to:
B. parasitic diarrhea.
C. fecal impaction.
D. fistula formation.
Constipation with overflow occurs when the rectum contains hard stool and soft feces above a leak around the mass of stool.
Urinary incontinence that occurs from the inability to hold urine once the stimulus to urinate is perceived is called _____ incontinence.
Urge incontinence is the inability to delay urination once the urge to void occurs.
You are examining the abdomen of a 45-year-old female patient. When percussing her urine-filled bladder, you will hear ____________ tones.
ANS: dull percussion
When examining the abdomen, what is the order for examination techniques? (Separate letters by a comma and space as follows: A, B, C, D.)
B. Light palpation
A, D, C, B
Inspection is always used as the first technique in all cases of physical examination, including the abdomen. In the abdomen the auscultation is completed prior to percussion or palpation.
Which two heart chambers are most anterior in the chest?
A. Both atria
B. Both ventricles
C. The right atrium and ventricle
D. The left atrium and ventricle
The most anterior surface of the heart is formed by the right ventricle. The heart is turned ventrally on its axis, putting its right side more forward. The left atrium is above the left ventricle, forming the most posterior aspect of the heart.
The condition in which a patient's heart is either rotated or displaced to the right or is situated as a mirror image of the expected position is called:
D. situs inversus.
Dextrocardia occurs when the heart is displaced or rotated to the right or is a complete mirror image of the expected finding. Amyloidosis is a metabolic disorder marked by amyloid deposits in organs and tissues. Coarctation is the compression of the walls of a vessel such as an aortic coarctation. Situs inversus occurs when the heart and stomach are displaced to the right and the liver is located to the left.
Heart position can vary depending on body habitus. In a short, stocky individual, you would expect the heart to be located:
A. more to the right and hanging more vertically.
B. more to the left and lying more horizontally.
C. riding higher in the chest and pushed anteriorly.
D. hanging lower in the chest and riding more vertically.
The position of the heart varies depending on body build, configuration of the chest, and level of the diaphragm. A tall, slender person's heart tends to hang vertically and is positioned centrally. A stocky, short person's heart tends to lie more to the left and more horizontally.
Which cardiac structure is responsible for the heart's pumping action?
The myocardium is the thick muscular middle layer that is responsible for the pumping action of the heart. The pericardium is the tough, double-walled, fibrous sac that protects the heart. The epicardium is the thin outermost muscle layer that covers the heart and extends onto the great vessels. The endocardium is the innermost layer that lines the chambers of the heart and covers heart valves.
Contraction of the ventricles causes:
A. closure of the atrioventricular valves.
B. closure of the pulmonic and aortic valves.
C. opening of the auricular septa.
D. opening of the mitral and tricuspid valves.
When the ventricles contract the semilunar valves, the pulmonic and aortic valves open, causing blood to rush into the pulmonary artery and the aorta. At this time, the tricuspid and mitral valves close, preventing backflow into the atria. When the atria contract, the tricuspid and mitral valves open, allowing blood flow into the ventricles. When the ventricles relax during diastole (ventricles are filling), the aortic and pulmonic valves close, preventing backflow into the ventricles.
Which two structures together form the primary muscle mass of the heart?
A. Right and left ventricles
B. Left ventricle and the aorta
C. Right and left atria
D. Left atrium and the pulmonary vein
The ventricles are large, thick-walled chambers that pump blood to the lungs and throughout the body. The right and left ventricles together form the primary muscle mass of the heart. The left ventricle pumps blood through the aortic valve into the aorta, which provides blood to the rest of the body. The right and left atria pump blood through the tricuspid and mitral valves to the ventricles. The pulmonary vein pumps oxygenated blood from the lungs to the left atria.
The major heart sounds are normally created by:
A. valves opening.
B. valves closing.
C. the rapid movement of blood.
D. rubbing together of the cardiac walls.
At the beginning of systole, ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valves closed, which produces the first heart sound S1 "lubb." When the pressure in the ventricles falls, when the ventricles are almost empty, below that of the aorta and pulmonary artery, the aortic and pulmonic valves close, producing the second heart sound S2 "dubb." Valve opening is usually a silent event.
Ms. Sharpe is a 22-year-old secretary. She presents with fatigue, malaise, and a rash. On auscultation of her heart, you note murmurs of mitral regurgitation and aortic stenosis. She reports a recent severe sore throat. You suspect:
B. acute rheumatic fever.
C. cardiac amyloidosis.
D. aortic sclerosis.
Acute rheumatic fever is a systemic connective tissue disease that occurs after a streptococcal pharyngitis or skin infection. It may result in serious cardiac valvular involvement of the mitral or aortic valve. Often the valve becomes stenotic and regurgitant. Prevention is adequate treatment of streptococcal pharyngitis or skin infections.
A grade IV mitral regurgitation murmur would:
A. be described as a diastolic murmur.
B. not be expected to have a thrill.
C. radiate to the axilla.
D. be heard best at the base.
A grade IV murmur would have a thrill; and a mitral regurgitation murmur is best heard at the apex, is holosystolic, and would radiate to the axilla.
Electrical activity recorded by the electrocardiogram (ECG) tracing that denotes the spread of the stimulus through the atria is the:
A. P wave.
B. PR interval.
C. QRS complex.
D. ST segment.
The P wave represents the spread of a stimulus through the atria (atrial depolarization). The PR interval is the time from the initial stimulation of the atria to the initial stimulation of the ventricles, usually 0.12 to 0.20 second. The QRS complex is the spread of a stimulus through the ventricles (ventricular depolarization), less than 0.10 second. The ST segment and T wave are the return of stimulated ventricular muscle to a resting state (ventricular repolarization).
The "pacing" structure of the heart's electrical activity is the:
A. AV node.
B. bundle of His.
C. Purkinje fibers.
D. sinoatrial (SA) node.
An electrical impulse stimulates each myocardial contraction, and this impulse originates in and is paced by the SA node.
Purkinje fibers are located in the:
A. sinoatrial node.
B. atrioventricular node.
D. aortic arch.
The Purkinje fibers are located in the ventricular myocardium.
The spread of the impulse through the ventricles (ventricular depolarization) is depicted on the ECG as the:
A. P wave.
B. QRS complex.
C. PR interval.
D. T wave.
The QRS complex is the spread of a stimulus through the ventricles and is measured as less than 0.10 second. The P wave is the spread of a stimulus through the atria. The PR interval is the time from the initial stimulation of the atria to initiation of stimulation of the ventricles. The T wave is the return of stimulated ventricular muscle to a resting state.
In the fetus, the right ventricle pumps blood through the:
A. left atrium.
B. ductus arteriosus.
D. foramen ovale.
The right ventricle of a fetal heart pumps blood through the patent ductus arteriosus rather than into the lungs, not through the left atrium, lungs, or foramen ovale.
In what age-group are the right and left ventricles equal in weight and muscle mass?
B. School-age children
D. Older adults
At the time of birth, the right and left ventricles are equal in weight and muscle mass because they both pump blood into the systemic circulation. Within 24 to 48 hours, closure of the ductus arteriosus and the interatrial foramen ovale causes pressure in the left atrium to increase. At this time, the right ventricles demand changes as the pulmonary circulation develops, and the left ventricle assumes total responsibility for providing systemic circulation. This results in an increase in the mass of the left ventricle. In older adults, the left ventricle wall thickens and the valves become fibrotic and calcified. The right and left ventricles are not equal in weight and muscle mass in school-age children, adolescents, or older adults.
Closure of the ductus arteriosus usually occurs:
A. 24 to 48 hours after birth.
B. after 7 days of life.
C. between the second and third month.
D. during the toddler period.
Closure of the ductus arteriosus usually occurs within 24 to 48 hours after birth.
The apex of a 2-month-old baby's heart typically lies closest to the:
A. fourth left intercostal space.
B. midsternal area.
C. midthoracic spinal area.
D. sixth left intercostal space.
In infants and young children, the heart lies more horizontally in the chest. The apex of the heart is located higher, sometimes well out into the fourth left intercostal space.
Normal cardiac changes that occur during pregnancy include:
A. decreased cardiac output.
B. increased thickness and mass of the left ventricle.
C. decreased heart rate.
D. dilation of the ventricles.
The maternal blood volume increases by 40% to 50% due to an increase in plasma volume. The heart works harder to accommodate the increased heart rate and stroke volume (both equal cardiac output), thereby resulting in the increase in left ventricle wall thickness and mass. The blood volume returns to prepregnancy levels within 3 to 4 weeks after delivery. As the uterus enlarges and the diaphragm moves upward, the heart is shifted horizontally and there is a slight axis rotation.
Which ECG change would not be expected as an age-related pattern?
A. First-degree block
B. Bundle branch block
C. Left ventricular hypertrophy
D. Ventricular fibrillation
Common ECG changes in older adults include first-degree atrioventricular block, bundle branch blocks, ST-T wave abnormalities, premature systole (atrial and ventricular), left anterior hemiblock, left ventricular hypertrophy, and atrial fibrillation.
Mr. O., age 50, comes for his yearly health assessment, which is provided by his employer. During your initial history-taking interview, Mr. O. mentions that he routinely engages in light exercise. At this time, you should:
A. ask if he makes his own bed daily.
B. have the patient describe his exercise.
C. make a note that he walks each day.
D. record "light exercise" in the history.
When Mr. O. says he engages in light exercise, have him describe his exercise. To qualify his use of the term "light," ask him the type, length of time, frequency, and intensity of his activities.
Pleural pain differs from chest discomfort caused by other conditions in that it is:
A. precipitated by coughing.
B. eased with deep breathing.
C. usually described as dull in nature.
D. related to time of day.
Pleural pain is precipitated by breathing and coughing and is usually described as a sharp pain that is present during respirations and absent during breath-holding.
Which of the following information belongs in the past medical history section related to heart and blood vessel assessment?
A. Adolescent inguinal hernia
B. Childhood mumps
C. History of bee stings
D. Previous unexplained fever
Previous unexplained fever should be included in the past medical history of a heart and blood vessel assessment. This incidence may be related to acute rheumatic fever, with potential heart valve damage.
A patient you are seeing in the emergency department for chest pain is believed to be having a myocardial infarction. During the health history interview of his family history, he relates that his father had died of "heart trouble." The most important follow-up question you should pose is which of the following?
A. "Did your father have coronary bypass surgery?"
B. "Did your father's father have heart trouble also?"
C. "What were your father's usual dietary habits?"
D. "What age was your father at the time of his death?"
A family history of sudden death, particularly in young and middle-aged relatives, significantly increases one's chance of a similar occurrence.
Which one of the following is a common symptom of cardiovascular disorders in the older adult?
B. Joint pain
C. Poor night vision
D. Weight gain
Common symptoms of cardiovascular disorders in older adults include confusion, dizziness, blackouts, syncope, palpitations, coughs and wheezes, hemoptysis, shortness of breath, chest pains or tightness, impotence, fatigue, and leg edema.
In the adult, the apical impulse should be most visible when the patient is in what position?
D. Right lateral recumbent
In most adults, the apical impulse should be visible at about the midclavicular line in the fifth left intercostal space, but it is easily obscured by obesity, large breasts, or muscularity. The apical impulse may become visible only when the patient sits upright and the heart is brought closer to the anterior wall. A visible and palpable impulse when the patient is supine suggests an intensity that may be the result of a problem. In most adults, the apical impulse will not be visible in the upright, lithotomy, or right lateral recumbent positions.
If the apical impulse is more vigorous than expected, it is called a:
If the apical impulse is more vigorous than expected, it is referred to as a lift or heave. A thrill is a palpable murmur. A bruit is an auscultated arterial murmur. A murmur is an auscultated sound that is caused by turbulent blood flow into, through, or out of the heart.
A palpable rushing vibration over the base of the heart at the second intercostal space is called a:
A thrill is a fine, palpable, rushing vibration¯a palpable murmur. Cardiac thrills generally indicate a disruption of the expected blood flow related to some defect in the closure of one of the semilunar valves (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial septal defect. A heave or lift is a more vigorous apical impulse. A lift is another term for a heave, which is a more vigorous apical impulse. A thrust is sudden, forcible forward movement.
An apical PMI palpated beyond the fifth intercostal space may indicate:
A. decreased cardiac output.
C. left ventricular hypertrophy.
An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may be indicative of left ventricular hypertrophy. Obesity, large breasts, and muscularity can obscure the visibility of the apical impulse.
A lift along the left sternal border is most likely the result of:
A. aortic stenosis.
B. atrial septal defect.
C. pulmonary hypertension.
D. right ventricular hypertrophy.
A lift along the left sternal border may be caused by right ventricular hypertrophy. A thrill indicates a disruption of the expected blood flow related to a defect in the closure of one of the semilunar valves, which is seen in aortic or pulmonic stenosis, pulmonary hypertension, or atrial septal defect.
To estimate heart size by percussion, you should begin tapping at the:
A. anterior axillary line.
B. left sternal border.
C. midclavicular line.
D. midsternal line.
Estimating the size of the heart can be done by percussion. Begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border.
Normal heart sounds are best heard:
A. directly over the semilunar and bicuspid heart valves.
B. over areas where blood flows after it passes through a valve.
C. near the carotid vessels.
D. over the central sternum.
Normal heart sounds are best heard in areas where the blood flows after it passes through a valve in the direction of blood flow.
To hear diastolic heart sounds, you should ask patients to:
A. lie on their back.
B. lie on their left side.
C. lie on their right side.
D. sit up and lean forward.
Left lateral recumbent is the best position to hear the low-pitched filling sounds in diastole with the bell of the stethoscope. Sitting up and leaning forward is the best position in which to hear relatively high-pitched murmurs with the diaphragm of the stethoscope. Right lateral recumbent position is the best position for evaluating right rotated heart of dextrocardia.
A third heart sound is created by:
A. atrial contraction.
B. ventricular contraction.
C. diastolic filling.
D. regurgitation between the right and left ventricles.
Diastole is a relatively passive interval until ventricular filling is almost complete. Diastole occurs when the ventricle is filling with blood from the atria and the filling sometimes produces a third heart sound, S3.
You are listening to a patient's heart sounds in the aortic and pulmonic areas. The sound becomes asynchronous during inspiration. The prevalent heart sound in this area is most likely:
S2 marks the closure of the semilunar valves, which indicates the end of systole, and is best heard in the aortic and pulmonic areas. It is higher pitched and shorter than S1. S2 typically splits during inspiration.
The bell of the stethoscope placed at the apex is more useful than the diaphragm for hearing:
A. pericardial friction rub.
B. high-pitched murmurs.
C. presystolic gallops.
D. systolic ejection sounds.
Using the bell of the stethoscope at the apex is more useful for hearing low-pitched presystolic gallops. The patient should lie in the supine or left lateral recumbent position.
You are conducting an examination of Mr. Curtis's heart and blood vessels and auscultate a grade III murmur. The intensity of this murmur is:
A. barely discernible.
B. moderately loud.
C. loud with palpable thrill.
D. very loud without a stethoscope.
The intensity of a grade III murmur is described as moderately loud. Barely discernible is a grade I murmur. Loud with a palpable thrill is a grade IV murmur. Very loud without a stethoscope is a grade VI murmur.
A grade I or II murmur, without radiation and of medium pitch, is a common variation found in:
A. school-age children.
B. older women.
C. middle-age men.
D. older adults.
Many murmurs, particularly in children and adolescents and especially in young athletes, have no apparent cause. These are usually grade I or II murmurs that are usually midsystolic and without radiation; are medium pitched; and are blowing, brief, and often accompanied by splitting of S2.
An example of a functional heart murmur is one that is caused by:
B. ventricular septal defect.
C. atrial septal defect.
D. mitral valve prolapse.
A functional heart murmur is a harmless heart murmur made by a healthy heart beating strongly. High-output demands that increase the speed of blood flow can cause murmurs. Anemia, pregnancy, and thyrotoxicosis can cause these functional heart murmurs.
Mr. Jones and his wife have brought in their infant daughter for a routine visit. A holosystolic murmur in an infant that is best heard along the left sternal border, is in the third to fifth intercostal spaces, and does not radiate to the neck is indicative of:
A. ventricular septal defect.
B. patent ductus arteriosus.
C. pulmonary stenosis.
Regurgitation through the ventricular septal defect results in a holosystolic murmur that is best heard along the left sternal border, is in the third to fifth intercostal spaces, and does not radiate to the neck.
A split second heart sound is:
B. greatest at the peak of inspiration.
C. heard best after forceful expiration.
D. supposed to disappear with deep inspiration.
Splitting of S2 is an expected event, because pressures are higher and depolarization occurs earlier on the left side of the heart. Ejection times on the right are longer, and the pulmonic valve closes a bit later than the aortic valve. Splitting of S2 is greatest at the peak of inspiration. During expiration, the split may disappear.
The earliest sign of heart failure in an infant is frequently:
A. liver enlargement.
B. fluid in the lungs.
C. enlarged thyroid.
D. clubbing of the fingers.
If heart failure is suspected, note that the infant's liver may enlarge before there is any suggestion of fluid in the lungs and that the left lobe of the liver may be more distinctly enlarged than the right.
Chest pain with an organic cause in a child is most likely the result of:
A. cardiac disease.
C. esophageal reflux.
Unlike chest pain in adults, chest pain in children and adolescents is seldom caused by a cardiac problem. More likely, the case is related to trauma, exercise-induced asthma, or cocaine use.
Which dysrhythmia is a physiologic event during childhood?
A. First-degree AV block
B. Mobitz type II
C. Multifocal PVCs
D. Sinus arrhythmia
Sinus arrhythmia is a physiologic event during childhood. The heart rate varies in a cyclic pattern, usually faster on inspiration and slower on expiration. The heart rates of children react with wider swings to stress, exercise, fever, or tension.
An increase in heart rate during inspiration, with a decrease in this rate during expiration, is an expected finding in:
A. adults under stress.
B. 4-year-old children.
C. pregnant women.
D. premature infants.
Sinus arrhythmia is a physiologic event during childhood. The heart rate of a child (4 years old) varies in a cyclic pattern, usually faster on inspiration and slower on expiration.
A condition that is likely to present with dizziness and syncope is:
A. bacterial endocarditis.
C. sick sinus syndrome.
Sick sinus syndrome (SSS) is a sinoatrial dysfunction that occurs secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart disease. SSS causes arrhythmias with subsequent syncope, transient dizzy spells, lightheadedness, seizures, palpitations, angina, or congestive heart failure (CHF). Bacterial endocarditis presents with prolonged fever, signs of neurologic dysfunctions, and sudden onset of CHF. Chest pain is an initial symptom in acute pericarditis along with a triphasic friction rub.
The auscultation of a triphasic friction rub in a patient with acute chest pain should lead you to suspect:
A. congestive heart failure.
D. cardiac tamponade.
Chest pain is the usual initial symptom in acute pericarditis, which is the inflammation of the pericardium. The key physical finding is the triphasic friction rub, which comprises ventricular systole, early diastolic ventricular filling, and late diastolic atrial systole. It is heard just to the left of the sternum in the third and fourth intercostal spaces and is characteristically scratchy. The auscultation of a triphasic friction rub in a patient with acute chest pain should not lead you to suspect congestive heart failure, endocarditis, or cardiac tamponade.
Your patient, who abuses intravenous (IV) drugs, has a sudden onset of fever and symptoms of congestive heart failure. Inspection of the skin reveals nontender erythematic lesions to the palms. These findings are consistent with the development of:
A. rheumatic fever.
B. cor pulmonale.
Endocarditis is a bacterial infection of the endothelial layer of the heart. It should be suspected with at-risk patients (such as IV drug abusers) who present with fever and sudden onset of congestive heart symptoms. The lesions described are Janeway lesions.
Thin-walled reservoirs of the heart are the:
The atria are small, thin-walled structures that act primarily as reservoirs for the blood returning to the heart from the venous system. The pericardium is a double-walled membranous fibroserous sac enclosing the heart and the bases of the great vessels. A sinus is a dilated channel for venous blood. The ventricles are large, thick-walled chambers that pump blood to the lungs and throughout the body. The ventricles are the primary muscle mass of the heart.
Fat deposits in the circulatory system of an older adult can lead to:
A. diffuse conduction disturbances.
B. exaggerated contractility.
C. heart failure.
D. thinning of the ventricles.
Atherosclerosis is a disease in which fat deposits (cholesterol) accumulate in the walls of the arteries, which can lead to heart failure or stroke.
The most helpful finding in determining left-sided heart failure is:
C. jugular vein distention.
D. S3 heart sound.
Evidence-based research has shown that the most helpful clinical examination finding supportive of left-sided heart failure is jugular vein distention.
During the auscultation of heart tones, you are uncertain whether the sound you hear is an S2 split. You should ask the patient to inhale deeply while listening at the _____ area.
Splitting of S2 is greatest at the peak of inspiration and best heard at the pulmonic site.
The heart sound that coincides with the carotid pulse is ________.
S1 marks the beginning of systole. S1 coincides with the rise (upswing) of the carotid pulse. Instruct patients to breathe normally and then hold their breath on expiration. Listen for S1 while you palpate the carotid pulse. S2 marks the start of diastole.
The middle ear contains the:
A. cerumen and sebaceous glands.
B. umbo and malleus.
C. vestibule and cochlea.
D. pars tensa and semicircular canals.
The middle ear contains the ossicles—three small bones: the malleus (umbo is part of the malleus), the incus, and the stapes. Cerumen and sebaceous glands lie outside the middle ear. The vestibule and the cochlea lie in the inner ear. The tympanic membrane separates the external ear from the middle ear and is composed of the pars tensa, and the semicircular canals lie in the inner ear.
The middle ear is normally filled with:
C. serous fluid.
D. cerebrospinal fluid.
The middle ear normally is an air-filled cavity in the temporal bone.
The hair cells of Corti and membrane of Corti:
A. produce a waxy lubricant.
B. protect the ear from foreign particles.
C. stimulate the eighth cranial nerve.
D. transmit vibrations to the ossicles.
Vibrations from the tympanic membrane cause the delicate hair cells of the organ of Corti to strike against the membrane of Corti, stimulating impulses in the sensory endings of the auditory division of the eighth cranial nerve.
The organ of Corti is a coiled structure located inside the:
A. cochlea in the inner ear.
B. pars flaccida in the tympanic membrane.
C. eustachian tube.
D. lateral aspect of the pinna.
The cochlea is a coiled structure within the inner ear that contains the organ of Corti.
Mrs. Kinder is a 39-year-old patient who presents to the office with complaints of an earache. In explaining to the patient about the function of her ears, which ear structure would you tell her is responsible for equalizing atmospheric pressure when swallowing, sneezing, or yawning?
A. Eustachian tube
B. Inner ear
C. Pars flaccida
D. Triangular fossa
The eustachian tube is a cartilaginous and bony passageway between the nasopharynx and the middle ear that opens briefly to equalize the middle ear pressure with that of the atmospheric pressure when swallowing, yawning, or sneezing.
Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using recreational drugs. On examination, you have noted a septal perforation. Which of the following recreational drugs is commonly associated with nasal septum perforation?
Long-term cocaine snorting causes ischemic necrosis of the septal cartilage and leads to perforation of the nasal septum.
A 5-year-old child presents with nasal congestion and a headache. To assess for sinus tenderness, you should palpate over the:
A. sphenoid and frontal sinuses.
B. maxillary and frontal sinuses.
C. maxillary sinuses only.
D. sphenoid sinuses only.
Only the maxillary and the frontal sinuses are accessible for physical examination; however, the young child does not develop frontal sinuses until 7 to 8 years of age.
An infant's auditory canal, compared with an adult's, is:
A. short, narrow, and straight.
B. short and curved upward.
C. long, narrow, and curved forward.
D. short and curved downward.
Compared with the adult's, the infant's auditory canal is shorter and has an upward curve, which is the reason that pulling the pinna down straightens the canal.
Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear drainage. When examining an infant's middle ear, the nurse should use one hand to stabilize the otoscope against the head while using the other hand to:
A. pull the auricle down and back.
B. hold the speculum in the canal.
C. distract the infant.
D. stabilize the chest.
The nurse should use the other hand to pull the auricle down and back in an effort to straighten the upward curvature of the canal.
The eruption of permanent teeth most commonly begins with:
A. upper central incisors.
B. upper canines.
C. lower central incisors.
D. lower canines.
The central incisors on the lower jaw usually erupt between 6 and 7 years of age as the first permanent teeth. Upper central incisors appear at 7 to 8 years of age. Upper canines appear at 11 to 12 years of age. Lower canines appear at 9 to 10 years of age.
Mrs. Donaldson is a 31-year-old patient who is pregnant. In providing Mrs. Donaldson with health care information, you will explain she can expect to experience:
A. more nasal stuffiness.
B. a sensitive sense of smell.
D. enhanced hearing.
Physiologic changes of pregnancy include nasal stuffiness, decreased sense of smell, impaired hearing, epistaxis, and a sense of fullness in the ears.
During what developmental stage are hoarseness, voice cracking, and a persistent cough common findings in females?
Laryngeal changes in pregnancy include hoarseness, deepening or cracking of the voice, vocal changes, and persistent cough.
Hearing tends to decline after 50 years of age because of deterioration of:
A. hair cells of the organ of Corti.
B. the eustachian tube.
C. the helix.
Hearing declines after 50 years of age due to degeneration of hair cells in the organ of Corti as well as atrophy of the hair cells in the cochlea.
You are performing hearing screening tests. Who would be expected to find difficulty in hearing the highest frequencies?
A. A 7 year old
B. An 18 year old
C. A 30 year old
D. A 50 year old
Sensorineural hearing loss begins after 50 years of age, initially with losses of high-frequency sounds and then progressing to tones of lower frequency.
Mr. Spencer presents with the complaint of hearing loss. You specifically inquire about current medications. Which medications, if listed, are likely to contribute to his hearing loss?
Ototoxic medications include aminoglycoside, salicylates, furosemide, streptomycin, quinine, ethacrynic acid, and cisplatin.
Mr. Williams, age 25, has recovered recently from an upper and lower respiratory infection. He describes a long-standing nasal dripping. He is seeking treatment for a mild hearing loss that has not gone away. Information concerning his chronic postnasal drip should be documented within which section of his history?
A. Age-specific data
B. Past medical data
C. Past surgical data
D. Social history
Information concerning the patient's chronic postnasal drip is part of the past medical history.
A 6-month-old who can hear well can be expected to:
A. exhibit the Moro reflex.
B. stop breathing in response to sudden noise.
C. turn his or her head toward the source of sound.
D. imitate simple words.
Six-month-old infants turn their head toward the source of sound; they start babbling, but they begin imitating speech sounds closer to 10 months of age. The Moro reflex and cessation of breathing in response to noise are lost by 3 months of age.
Which ethnicity is associated with the highest rate of oral cancers?
C. Mexican American
D. African American
Risk factors for oral cancer include age older than 40 years, male gender, African American ethnicity, excessive alcohol use, dental lesions, tobacco use, occupational hazards (e.g., textile industry and leather manufacturing), and systemic disease (e.g., pernicious or iron-deficiency anemia, HIV infection, lichen planus, and previous malignancy).
To approximate vocal frequencies, which tuning fork should be used to assess hearing?
A. 100 to 300 Hz
B. 200 to 400 Hz
C. 500 to 1000 Hz
D. 1500 to 2000 Hz
Use of 500 to 1000 Hz approximates vocal frequencies.
You are using a pneumatic attachment on the otoscope while assessing tympanic membrane movement. You gently squeeze the bulb but see no movement of the membrane. Your next action should be to:
A. remove all cerumen from the canal.
B. change to a rubber speculum.
C. squeeze the bulb with more force.
D. insert the speculum to depth of 2 cm.
When using the pneumatic attachment, to see tympanic movement there should be a seal around the speculum to block outside air. In this manner, the normal tympanic membrane moves as a result of pressure changes from the insufflator bulb. A soft rubber speculum is recommended to establish the seal.
An ear auricle with a low-set or unusual angle may indicate chromosomal aberration or:
A. digestive disorders.
B. skeletal anomalies.
C. renal disorders.
D. heart defects.
An auricle with a low-set or unusual angle may indicate chromosomal aberrations or renal disorders.
When conducting an adult otoscopic examination, you should:
A. position the patient's head leaning toward you.
B. grasp the handle of the otoscope as you would a baseball bat.
C. select the largest speculum that will fit in the canal.
D. ask the patient to keep his eyes closed.
When conducting an adult otoscopic examination, select the largest speculum that will comfortably fit in the patient's ear. When you are conducting an adult otoscopic examination, the patient's head should be positioned toward the opposite shoulder. Hold the handle of the otoscope between the thumb and the index finger, supporting it on the middle finger. There is no reason for the patient to keep the eyes shut.
Normal tympanic membrane color is:
B. chalky white.
D. pearly gray.
The expected normal tympanic membrane color is pearly gray.
Bulging of an amber tympanic membrane without mobility is most often associated with:
A. middle ear effusion.
B. healed tympanic membrane perforation.
C. impacted cerumen in the canal.
D. repeated and prolonged crying cycles.
An amber color, with bulging of the tympanic membrane and without mobility or redness, most often indicates the presence of fluid in the middle ear.
In the presence of otitis externa, tympanic membrane perforation, or myringotomy tubes, you should:
A. avoid performing otoscopic examinations.
B. clean the inner ear with soap.
C. instill alcohol into the ear.
D. avoid instilling fluids.
Any ear irrigation should be avoided in the presence of otitis externa, a perforated tympanic membrane, myringotomy tubes, or mastoid cavity. The presence of otitis externa, tympanic membrane perforation, or myringotomy tubes is not a contraindication for otoscopic examinations. You should not clean the inner ear with soap. Only the auricle can be cleaned with soap. You should not instill alcohol into the ear.
When hearing is evaluated, which cranial nerve is being tested?
Cranial nerve VIII, the vestibulocochlear nerve, is associated with hearing.
Speech with a monotonous tone and erratic volume may indicate:
A. otitis externa.
B. hearing loss.
C. serous otitis media.
Speech with a monotonous tone and erratic volume may indicate hearing loss.
Placing the base of a vibrating tuning fork on the midline vertex of the patient's head is a test for:
A. air conduction of sound.
B. bone versus air conduction.
C. lateralization of sound.
D. mallear auditory ability.
Placing the fork on the midline vertex of the patient's head is the Weber test, a test for conductive hearing loss that lateralizes to the affected ear.
To perform the Rinne test, place the tuning fork on the:
A. top of the head.
B. mastoid bone.
D. preauricular area.
The fork is initially placed against the mastoid bone for the Rinne test, a test for sensorineural loss.
You are performing Weber and Rinne hearing tests. For the Weber test, the sound lateralized to the unaffected ear; for the Rinne test, air conduction-to-bone conduction ratio was less than 2:1. You interpret these findings as suggestive of:
A. a defect in the inner ear.
B. a defect in the middle ear.
C. otitis externa.
D. impacted cerumen.
These results are consistent with a sensorineural hearing loss, a defect in the inner ear. Otitis externa and impacted cerumen are conditions of the external ear that can cause conductive hearing problems.
Nasal symptoms that imply an allergic response include:
A. purulent nasal drainage.
B. bluish-gray turbinates.
C. small, atrophied nasal membranes.
D. firm consistency of turbinates.
Nasal symptoms that imply an allergic response include bluish gray or pale pink nasal turbinates that are swollen and boggy and a transverse crease at the junction between the cartilage and the bone of the nose.
You are interviewing a parent whose child has fever, is pulling at her right ear, and is irritable. You ask the parent about the child's appetite and find that the child has a decreased appetite. This additional finding is more suggestive of:
A. acute otitis media.
B. otitis externa.
C. serous otitis media.
D. middle ear effusion.
Anorexia is an initial symptom of acute otitis media.
A smooth red tongue with a slick appearance may indicate:
A. niacin or vitamin B12 deficiency.
B. oral cancer.
C. recent use of antibiotics.
D. fungal infection.
A smooth red tongue with a slick appearance may indicate a niacin or vitamin B12 deficiency. Oral cancer involves lesions; recent use of antibiotics can turn the tongue yellow-brown to black and hairy; and fungal infections result in slightly raised white, cream-colored, or yellow spots in the mouth.
White, rounded, or oval ulcerations surrounded by a red halo and found on the oral mucosa are:
A. Fordyce spots.
B. aphthous ulcers.
C. Stensen ducts.
Aphthous ulcers are white, round, or oval lesions surrounded by a red halo and appear on the buccal mucosa. Fordyce spots are ectopic sebaceous glands that appear on the buccal mucosa and lips as numerous small, yellow-white, raised lesions. Stensen ducts are parotid gland outlets and should appear as whitish yellow or whitish pink protrusions in approximate alignment with the second upper molar. Leukoedema appears on the buccal mucosa as a diffuse filmy grayish surface with white streaks, wrinkles, or milky alteration.
A hairy tongue with yellowish brown to black elongated papillae on the dorsum:
A. is indicative of oral cancer.
B. is sometimes seen following antibiotic therapy.
C. usually indicates vitamin deficiency.
D. usually indicates anemia.
Recent antibiotic use can turn the tongue yellow-brown to black and make it appear hairy. Oral cancer involves lesions. A smooth red tongue with a slick appearance may indicate a niacin or vitamin B12 deficiency. Pallor usually indicates anemia.
To inspect the lateral borders of the tongue, you should:
A. ask the patient to extend the tongue outward.
B. insert the tongue blade obliquely against the tongue.
C. lift the tongue upward with gloved fingers.
D. pull the gauze-wrapped tongue to each side.
To inspect the lateral borders of the tongue, you should wrap the tongue with a piece of gauze, then pull the tongue to each side for inspection.
A newborn whose serum bilirubin is greater than 20 mg/100 mL has a risk of later:
A. hearing loss.
C. tooth decay.
Risk factors for hearing loss in infants include infection, irradiation, drug abuse, and syphilis in the mother, as well as birth weight less that 1500 g, excessively high bilirubin level, infections (e.g., bacterial meningitis and recurrent otitis media), cleft palate, craniofacial abnormalities, ototoxic antibiotic use, head trauma, and hypoxic episodes in infancy
Which variation may be an expected finding in the ear examination of a newborn?
A. Diffuse light reflex
B. Purulent material in the ear canal
C. Redness and swelling of the mastoid process
D. Small perforations of the tympanic membrane
The newborn's tympanic membrane does not become conical for several months; therefore the light reflex appears diffuse.
For best results, otoscopic and oral examination in a child should be:
A. conducted at the beginning of the assessment.
B. done after inspection.
C. performed at the end of the examination.
D. performed before palpation.
Because young children often resist otoscopic and oral examination, it may be wise to postpone these procedures until the end, after you have gained some trust.
Which abnormality is common during pregnancy?
A. Eruption of additional molars
B. Hypertrophy of the gums
C. Otitis externa
D. Otitis media
The gums of pregnant women may appear reddened, swollen, and spongy, with the hypertrophy resolving within 2 months of delivery.
Intense pain with movement of the pinna is most closely associated with:
A. otitis media with effusion.
B. otitis externa.
C. purulent otitis media.
D. bacterial otitis media.
Otitis externa (swimmer's ear) should be suspected when pulling of the pinna reproduces ear pain.
Expected physical changes associated with older adults include:
A. shiny buccal mucosa.
B. shorter teeth.
C. wetter nasal mucosa.
D. bristly hairs in the vestibule.
With age, buccal mucosa becomes less shiny, teeth appear longer due to gums receding, nasal mucosa are drier, and more bristly hairs appear in the nose, especially in men.
Severe vertigo, tinnitus, and progressive hearing loss are characteristic of:
B. Ménière disease.
D. cocaine abuse.
The classic triad of Ménière disease is vertigo, tinnitus, and progressive hearing loss.
In adults, the length of the external auditory canal is _____ cm.
The external ear canal is approximately 2.5 cm long in adults.
When you ask the patient to identify smells, you are assessing cranial nerve _____.
The first cranial nerve, the olfactory nerve, is tested when you ask a patient to identify different smells.
The structures that lie along the lateral wall of the nasal cavity near the facial cheek are the _____ sinuses.
The maxillary sinuses lie along the nasal cavity near the cheek; the ethmoid sinuses lie behind the frontal sinuses near the superior portion of the nasal cavity; and the paranasal sinuses are extensions of the nasal cavities within the skull.
Mr. Akins is a 78-year-old patient who presents to the clinic with complaints of hearing loss. Which of the following are changes in hearing that occur in the elderly? Select all that apply.
A. Results from cranial nerve VII
B. Progression is slow
C. Loss of high frequency
D. Bone conduction heard longer than air conduction
E. Sounds may be garbled and difficult to localize
F. Unable to hear in a crowded room
ANS: C, E, F
The anteroposterior diameter of the chest is normally approximately the same as the transverse diameter in which age group?
B. School-age children
D. Young adults
The chest of infants is generally round with equal dimensions of anteroposterior and transverse diameters.
A 44-year-old male patient who complains of a cough has presented to the emergency department. He admits to smoking 1 pack per day. During your inspection of his chest, the most appropriate lighting source to highlight chest movement is:
A. bright tangential lighting.
B. daylight from a window.
C. flashlight in a dark room.
D. fluorescent ceiling lights.
Bright tangential light is best for visualizing chest movements.
When auscultating the apex of the lung, you should listen at a point:
A. even with the second rib.
B. 4 cm above the first rib.
C. higher on the right side.
D. on the convex diaphragm surface.
The apex of the lung is 4 cm above the first rib.
You are documenting a rash between the eighth and ninth ribs on the lateral border. This intercostal space will be documented in terms of the:
A. rib immediately above it.
B. rib immediately below it.
C. number of centimeters it is positioned below the clavicle.
D. number of inches it is positioned below the clavicle.
The number of each intercostal space corresponds to that of the rib immediately above it.
To count the ribs and the intercostal spaces, you begin by palpating the reference point of the:
A. distal point of the xiphoid.
B. manubriosternal junction.
C. suprasternal notch.
D. acromion process.
The angle of Louis, the junction of the manubrium and the sternum, corresponds to the second rib, the reference point for counting ribs and intercostal spaces.
The lung begins its gestational development from the:
At about 4 weeks' gestation, the lung is a groove on the ventral wall of the gut.
Fetal gas exchange is mediated by the:
C. amniotic fluid.
The placenta is the source of fetal gas exchange; the lungs contain no air and the alveoli are collapsed. It is not mediated by the heart.
The foramen ovale should close:
A. by 24 weeks of gestation.
B. within minutes of birth.
C. by 4 weeks of age.
D. By 12 months of age.
The decrease in pulmonary pressures within the first minutes of life leads to closure of the foramen ovale.
Increased oxygen tension in the arterial blood of a newborn infant causes:
A. closure of the ductus arteriosus.
B. hyperinflation of the lungs.
C. passive respiratory movements.
D. reopening of the foramen ovale.
Increased oxygen tension in the arterial blood usually stimulates contraction and closure of the ductus arteriosus.
To accommodate the enlarging uterus of pregnancy, chest changes result in:
A. intercostal muscle atrophy.
B. lowering of the resting diaphragm.
C. a decrease in alveoli expansion.
D. an increase in the subcostal angle.
The subcostal angle progressively increases from approximately 68.5 degrees to 103.5 degrees in later pregnancy.
The characteristic barrel chest of the older adult is due to a combination of factors, including:
A. skeletal changes of aging.
B. increased muscular expansion of the chest wall.
C. less fibrous alveoli.
D. increased vital capacity.
Skeletal changes associated with aging include an emphasis of the dorsal curve of the thoracic spine that contributes to a barrel chest.
Nancy Walker is a 16-year-old girl who presents to the clinic with complaints of severe, acute chest pain. Her mother reports that, apart from occasional colds, Nancy is not prone to respiratory problems. What potential risk factor is most important to assess with regard to Nancy's current problem?
A. Anorexia symptoms
B. Cocaine use
C. Last menses
D. Signs of rheumatic fever
Illegal drug use of cocaine is especially important to prioritize as a social history question for all adolescents and adults who complain of severe chest pain. Cocaine can lead to tachycardia, hypertension, coronary arterial spasm with infarction, and pneumothorax.
The patient tells you that she uses herbal and other alternative therapies to maintain her health. This information is recorded in the:
A. past medical history.
B. chief complaint.
C. social history.
D. family history.
Patient data concerning the use of herbal or other remedies and other complementary or alternative therapies are recorded within the social history component of the history and physical.
Mr. Curtis is a 44-year-old patient who has presented to the emergency department with shortness of breath. During the history, the patient describes shortness of breath that gets worse when he sits up. To document this, you will use the term:
Dyspnea that increases in the upright posture is called platypnea. Orthopnea is dyspnea that worsens when the person lies down. Tachypnea is an increased respiratory rate. Bradypnea is a decreased respiratory rate.
Bradypnea may accompany:
A. a subconscious response to observation.
B. an excellent level of cardiovascular fitness.
D. severe pain from a rib fracture.
Bradypnea, a respiratory rate slower than 12 breaths per minute, may be seen with cardiorespiratory fitness. Tachypnea is seen with a subconscious response to observation, with ascites, and with severe pain from a rib fracture.
Which chest structure contains all the thoracic viscera except the lungs?
The mediastinum, situated between the lungs, contains all the thoracic viscera except the lungs. The sternum is composed of the manubrium and xiphoid.
Which bronchial structure(s) is(are) most susceptible to aspiration of foreign bodies?
A. Left mainstem bronchus
B. Terminal bronchioles
C. Right mainstem bronchus
D. Respiratory bronchioles
The right mainstem bronchus has a more downward slope and is less angled than the left bronchus. Therefore it is more likely to be a site of aspiration and is a more likely site for endotracheal tubes that are advanced too far.
Which finding suggests a minor structural variation?
A. Barrel chest
B. Clubbed fingers
C. Pectus carinatum
D. Chest wall retractions
Pectus carinatum (pigeon chest) is a minor structural variation. Barrel chest, clubbing of the fingers, and chest wall retractions result from compromised respirations.
Ms. Rudman, age 74, has no known health problems or diseases. You are doing a preventive health care history and examination. Which symptom is associated with intrathoracic infection?
A. Barrel chest
B. Cor pulmonale
C. Funnel chest
D. Malodorous breath
Intrathoracic infections may make the breath malodorous
The best time to observe and count respirations is while:
A. the patient is answering questions.
B. weighing the patient.
C. palpating the pulse.
D. the patient is sleeping.
Counting respirations while you palpate the pulse does not make the patient self-conscious, because the patient expects you to be counting the pulse. Respiratory patterns change as the patient speaks. Attempting to count during weighing would make the patient self-conscious and affect the respiratory rate. Respiratory patterns change as the patient sleeps
As you take vital signs on Mr. Barrow, age 78, you note that his respirations are 40 per minute. He has been resting, and his mucosa is pink. Concerning Mr. Barrow's respirations, you would:
A. document his rate as normal.
B. do nothing because his color is pink.
C. note that his rate is below normal.
D. report that he has an above-average rate.
The normal adult respiratory rate is 12 to 20 breaths per minute, and the ratio of breaths to heartbeats is 1:4. A respiratory rate of 40 breaths per minute is not within the normal range and should be documented as above average.
In which patient situation would you expect to assess tachypnea?
A. Patient who is depressed
B. Patient who abuses narcotics
C. Patient with metabolic acidosis
D. Patient with myasthenia gravis
In metabolic acidosis, the body compensates by increasing the respiratory rate to blow off the excess carbon dioxide. A patient who is depressed, abuses narcotics, or has myasthenia gravis would have respiratory depression.
What term would you use to document a respiratory rate greater than 20 breaths per minute in an adult?
Tachypnea is a respiratory rate greater than 20 breaths per minute. Dyspnea, orthopnea, and platypnea describe respiratory effort, not rate.
Respiratory effort usually exhibited by a patient with cerebral brain damage is called:
A. Cheyne-Stokes respiration.
B. paroxysmal nocturnal dyspnea.
C. Kussmaul breathing.
D. Biot respiration.
Cheyne-Stokes respirations occur in children and older adults during sleep, but otherwise occur in seriously ill patients, particularly those with brain damage at the cerebral level.
Which site of chest wall retractions indicates a more severe obstruction in the asthmatic patient?
A. Lower chest
B. Along the anterior axillary line
C. Above the clavicles
D. At the nipple line
Asthma more commonly produces retractions of the lower chest. The more severe the obstruction, the greater the negative pressure produced in the chest during inspiration, and retractions are manifested in the upper thorax.
Laryngeal obstructions would elicit which breath sound?
Obstructions high in the respiratory tree (e.g., laryngeal obstructions) are characterized by stridor.
Mr. L. has cyanotic lips and nail beds. His lips are pursed, and he has nasal flaring. You suspect he is having cardiac or pulmonary difficulty. What additional sign would support this impression?
A. Callus formation on the heels
B. Clubbing of the fingers
C. Graying hair
D. Swollen toes and ankles
Clubbing of the fingers suggests pulmonary or cardiac difficulty.
Breath odors may clue the examiner to certain underlying metabolic conditions. The odor of ammonia on the breath may signify:
C. hepatic failure.
D. diabetic ketoacidosis.
An ammonia-like breath odor suggests uremia, a renal condition. A cinnamon-like breath odor suggests tuberculosis. A breath odor resembling musty fish or clover suggests hepatic failure. A sweet, fruity breath odor suggests diabetic ketoacidosis.
An expected finding of chest palpation in the adult would be:
A. a costal angle of 100 degrees.
B. cracking over the sternal notch.
C. greater right chest expansion.
D. inflexibility of the xiphoid.
The sternum and xiphoid are relatively inflexible in adults. The expected normal costal angle in the adult is 90 degrees. Cracking over the sternal notch is not an expected finding of chest palpation in the adult. Normally, the chest moves symmetrically in the adult.
You would expect to document the presence of a pleural friction rub for a patient being treated for:
A pleural friction rub is caused by inflammation of the pleural surfaces and would be expected to be auscultated with pleurisy.
Which type of apnea requires immediate action?
A. Primary apnea
B. Secondary apnea
C. Sleep apnea
D. Periodic apnea of the newborn
Secondary apnea is a grave condition, and unless resuscitative measures are instituted immediately, breathing will not resume spontaneously. Primary apnea is self-limiting. Sleep apnea should be evaluated but does not require immediate action. Periodic apnea of the newborn is a normal condition.
In the most effective percussion technique for the posterior lung fields, the patient cooperates by:
A. folding the arms in front.
B. bending the head back.
C. standing and bending forward.
D. lying on the side and extending the top arm.
Having the patient sit with the head forward and the arms folded in front moves the scapula laterally, exposing more lung to percussion.
The examiner percusses for diaphragmatic excursion along the:
B. midvertebral line.
C. midaxillary line.
D. scapular line.
The technique for diaphragmatic excursion is to percuss along the scapular line after the patient inhales deeply and then mark the site where resonance changes to dullness, representing the diaphragm. The sequence is repeated with exhalation.
The diaphragm of the stethoscope is better than the bell for auscultation of the lungs because it:
A. amplifies all types of sounds.
B. filters extraneous sounds.
C. pinpoints focal sound areas.
D. transmits high-pitched sounds.
The diaphragm is the better source because it transmits the normally high-pitched sounds of the lung, and it has a broader area from which to listen. Unless specially modified, the stethoscope does not amplify sound, filter extraneous sounds, or pinpoint focal sound areas.
Breath sounds normally heard over the trachea are called:
The sounds highest in intensity and pitch are the bronchial sounds, which are normally heard over the trachea.
With consolidation in the lung tissue, the breath sounds are louder and easier to hear, whereas healthy lung tissue produces softer sounds. This is because:
A. consolidation echoes in the chest.
B. consolidation is a poor conductor of sound.
C. air-filled lung sounds are from smaller spaces.
D. air-filled lung tissue is an insulator of sound
Air is a poor conductor of sound. More dense consolidation promotes louder sounds and is a better conductor of sound. Consolidation is a better conductor of sound than air is. Breath sounds are easier to hear when the lungs are consolidated; the mass surrounding the tube of the respiratory tree promotes sound transmission better than do air-filled alveoli.
The middle lobe of the right lung is best auscultated in the:
A. anterior chest.
B. posterior chest.
D. midclavicular line.
The sounds of the middle lobe of the right lung are best heard in the right axilla.
Your older clinic patient is being seen today as a follow-up for a 2-day history of pneumonia. The patient continues to have a productive cough, shortness of breath, and lethargy and has been spending most of the day lying in bed. You should begin the chest examination by:
A. percussing all lung fields.
B. auscultating the lung bases.
C. determining tactile fremitus.
D. estimating diaphragmatic excursion.
Because the patient has consolidation and has been recumbent and fatigued, the most appropriate first step is to listen to the lung bases before the patient gets exhausted. The lung bases are the most likely sites of adventitious sounds.
Your trauma patient has no auscultated breath sounds in the right lung field. You can hear adequate sounds on the left side. A likely cause of this abnormality could be that the patient:
A. has a closed head injury.
B. has fluid in the pleural space.
C. is moaning and in severe pain.
D. is receiving high-flow oxygen.
Trauma to the chest can cause an exudative pleural effusion or pneumothorax. In the affected areas, the breath sounds are diminished to absent.
The American Thoracic Society suggests replacing the term rales with:
The American Thoracic Society has suggested that the term rales be replaced with crackles to more precisely describe the sound.
To distinguish crackles from rhonchi, you should auscultate the lungs:
A. before and after the patient coughs.
B. first at the lung base, then at the apex.
C. with the patient inhaling, then exhaling.
D. with the patient recumbent, then sitting.
To distinguish between crackles and rhonchi, ask the patient to cough and auscultate again over the same area. Because they reflect secretions in larger airways, rhonchi can clear with coughing.
A musical squeaking noise heard on auscultation of the lungs is called:
A. friction rub.
Wheezing is a continuous, high-pitched musical sound that can be heard on inspiration and expiration.
To distinguish between a respiratory friction rub and a cardiac friction rub, ask the patient to:
A. hold the breath.
B. lean forward.
C. say "ninety-nine" while you palpate the anterior chest.
D. identify the location of the pain.
A respiratory friction rub results when inflamed pleura rub against each other during the respiratory cycle; if the breath is held, the rub stops.
In what position can the mediastinal crunch (Hamman sign) best be heard?
A. A supine position
B. Lying on the left side
C. Sitting completely upright
D. With the head elevated 30 degrees
Hamman sign occurs with mediastinal emphysema. The adventitious breath sounds are synchronous with the heartbeat and are best heard when the patient leans to the left or lies down on the left side (these maneuvers bring the heart muscle closer to the chest wall).
Changes in the clarity and volume of spoken sounds during auscultation of the lungs can help you distinguish:
A. consolidation from airway constriction.
B. foreign body from purulent exudate.
C. pulmonary edema from pleurisy.
D. right from left tracheal deviation.
When chest auscultation results in decreased breath sounds or wheezes, the examiner can use techniques that involve the spoken word to distinguish adventitious breath sounds caused by consolidation from those caused by narrowing of a patent lumen.
During a chest assessment, you note the patient's voice quality while auscultating the lung fields. The voice sound is intensified, the voice has a nasal quality, and the e's sound like a's. This is indicative of:
A. lung consolidation.
C. bronchial obstruction.
Vocal resonance, as described, indicates lung consolidation. Sounds are transmitted more clearly through consolidation rather than air.
While auscultating the lung fields, you note that the patient's voice sound is intensified, the voice has a nasal quality, and e's sound like a's. This describes:
Egophony is marked by increased intensity of the spoken voice, a nasal quality to the voice, and e's that become stuffy, broad a's.
Tactile fremitus is best felt:
A. along the costal margin and xiphoid process.
B. in the suprasternal notch along the clavicle.
C. parasternally at the second intercostal space.
D. posterolaterally beneath the scapula.
Fremitus is best palpated at the second intercostal space, which also corresponds to the bifurcation of the bronchi.
How is the sputum of a viral infection different from the sputum of a bacterial infection?
A. Sputum production is greater with viral conditions than with bacterial infections.
B. The sputum is odorous in viral conditions and nonodorous in bacterial infections.
C. The sputum is yellow, green, or rust colored in bacterial infections and mucoid in viral infections.
D. The sputum is much thinner in bacterial infections than in viral infections.
The characteristic most likely to differentiate viral sputum from bacterial sputum is the sputum's color. Viral infections typically produce mucoid sputum, whereas bacterial infections produce yellow, green, or rust-colored sputum.
A cause for alarm during chest assessment of a newborn is:
C. gurgles from the gastrointestinal tract.
Stridor is alarming at any age. Crackles and rhonchi at birth are due to the presence of remaining fetal fluid and are not a cause for alarm. Intermittent gurgles are bowel sounds transmitted through the thin-walled chest and are not a cause for alarm.
Which of the following is an expected finding in newborns but a cause for concern in adults?
A. Mottling of the thorax
B. Sternal retractions
D. Nasal flaring
Nasal flaring is common in infants, because children are obligate nose breathers; however, it is a sign of distress in the adult. Other findings that would be a concern in adults but not in infants are respiratory grunting and periodic breathing. Mottling of the thorax and sternal retractions are a sign of distress in all ages. Cough is rare in the newborn and would be considered a problem.
Loud, harsh bronchovesicular breath sounds in young children are an indication of:
A. the accumulation of fluid.
B. malignant tumors or solid masses.
C. normal, thin chest wall structures.
D. pus-filled abscesses and tumors.
The chest wall of a young child is usually thin and therefore normally able to transmit loud, harsh, and more bronchial breath sounds than are heard in adults.
Expected respiratory changes of normal aging include:
A. increased chest expansion.
B. more frequent use of respiratory muscles.
C. accentuated lumbar curve.
D. more prominent bony structures.
Marked bony prominences are seen in older adults because of loss of subcutaneous tissue. Chest expansion is decreased in older adults. Older adults show less use of respiratory muscles because of muscle weakness. The lumbar curve is flattened in older adults.
Which symptom is the most significant indicator of asthma and should be identified in the health history?
B. Persistent cough
C. Coexistent skin conditions
D. Chest pain
All the symptoms listed are associated with asthma; however, a persistent cough may be the only manifestation. A detailed description of cough should be included in the health history for any patient with a respiratory complaint.
Dullness to percussion in intercostal spaces suggests the presence of:
A. cor pulmonale.
D. sickle cell disease.
Resonance is the expected percussion tone over normal lung tissue, which is accessible in the intercostal spaces. Dullness indicates an area of consolidation, as is seen with pneumonia.
Which condition requires immediate emergency intervention?
A. Patient with pleuritic pain without dyspnea
B. Patient with fever and a productive cough
C. Patient with tachypnea but no chest retractions
D. Patient with absent breath sounds and dull percussion tones
A patient who experiences unexpected pleuritic pain without prior respiratory distress or dyspnea most likely has developed a pulmonary embolism, a condition with a high mortality rate.
A 29-year-old patient presents with a new complaint of productive cough with purulent sputum. He also complains of right lower quadrant abdominal pain. You suspect pneumonia in which lobe?
A. Right lower
B. Right upper
C. Left upper
D. Left lower
Right lower lobe pneumonia can stimulate the tenth thoracic nerve, causing right lower quadrant pain and simulating an abdominal process.
Both pleural effusion and lobar pneumonia are characterized by ___________ percussion.
dullness heard on
Pleural effusion and lobar pneumonia are more dense than air, with an expected finding of dullness on percussion. Tympany is expected over hollow organs, such as the stomach; resonance and hyperresonance are heard over air-filled areas.
The respiratory rate of a sleeping newborn is expected to be _____ breaths per minute.
40 to 60
The expected respiratory rate for infants is 40 to 60 breaths per minute.
In barrel chest, the ratio of anteroposterior diameter to transverse (lateral) diameter is _____.
In a barrel chest, an increase in the chest anteroposterior diameter leads to an increase in the thoracic ratio (anteroposterior to transverse diameters) of 1.0, wherein the chest is as wide as it is thick.
A pregnant woman is expected to develop:
A. tachypnea and decreased tidal volume.
B. deep breathing but not more frequent breathing.
C. dyspnea and increased functional residual capacity.
D. bradypnea and increased tidal volume.
In a pregnant woman, the tidal volume and vital capacity increase, the functional residual capacity decreases, and the woman breathes more deeply but not more frequently.