Health Assessment : Exam 2 Study Guide

A35 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 nurses preliminary analysis, based on this history, is that this patient may be suffering from
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Terms in this set (48)
(A,C,D) Voice sounds are faint, muffled and almost inaudible when patient whispers one, two, three in a very soft voice
When patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish what is being said
As the patient says a long ee- ee-ee sound, the examiner also hears a long ee-ee-ee sound
When auscultating the lungs of an adult patient, the nurse notes low pitched, soft breath sounds are heard over the posterior lobes, with inspiration being longer than expiration. The nurse interprets that these sounds areC. Vesicular breath sounds and normal in that locationThe nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?D. Lungs are less elastic and distensible, which decreases their ability to collapse and recoilThe nurse is assessing the apical pulse of a 3-month old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result asA. Normal for his ageA mother brings her 3 month old infant to the clinic for evaluation of a cold. She tells the nurse he has had runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next action should beB. Recognize there are serious signs and contact the physicianWhat are signs and symptoms of respiratory distress?Tachypnea, retractions, nasal flaring, cyanosis, see-saw respiration, decreased lung sounds, gasping later and ominousIn assessing the carotid arteries of an older patient with cardiovascular disease, the nurse wouldB. Listen with the bell of the stethoscope to assess for bruitsWhen the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique?C. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breathe, exhale, and briefly hold it.Which of these statements describes the closure of valves in a normal cardiac cycleC. The tricuspid valve closes slightly later than the mitral valveThe nurse if performing a middle ear assessment on a 15 year old patient who has had a history of chronic ear infections. When examining the right tympanic membranes, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse shouldB. Know that these are scars caused from frequent ear infectionsDuring an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?D. Yeast or fungal infectionWhen examining the ear with an otoscope, the nurse notes that the tympanic membraneB. Pearly gray and slightly concaveWhile performing the otoscopic examination of a 3 year old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is BRIGHT RED and that the LIGHT REFLEC is NOT VISIBLE.B. Acute otitis mediaWhen performing an otoscopic examination of a 5 year old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound when swallowing. The preliminary analysis based on this information is that the childMost likely has serous otitis mediaA mother is concerned because her 18 month old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse best response would beThis is a normal number or teeth for an 18 - month old.A patient has been admitted to the emergency department with a possible medical diagnosis of Pulmonary embolism. The nurse expects to see which assessment findings related to this condition?C. Chest pain that is worse on deep inspiration and dyspneaDuring an assessment, the nurse shows that expected assessment findings in the normal adult lung include the presence ofC. Muffled voice sounds and symmetric tactile fremitusDuring percussion the nurse knows that a dull percussion note elicited over a lung lobe must likely result fromD. Increased density of lung diseaseWhen assessing the respiratory system of a four year old child, which of these findings would the nurse expectPresence of brochovesicular breath sounds in the peripheral lung fields.During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which stimulation?When part of the lung is obstructed or collapsedA 72 year old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would beD. Have you noticed any dryness in your mouthWhen listening to heart sounds, the nurse knows the valve closures that can be heard best at the bast of the heartC. Aortic and pulmonicThe nurse is preparing to auscultate for heart sounds. Which technique is correctB. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, the over the apexA patient comes to the emergency department after a boxing match, and his left eye is swollen and almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:B. Shadow or diminished in one quad or one half of visual fieldWhich of these assessment findings would the nurse expect to see when examining the eyes of black patients?B. Dark retinal backgroundThe nurse is performing an otoscopic examination on an adult. Which of these actions is correct?C. Pulling the pinna up and back before inserting the speculumThe nurse is preparing to do an otoscopic examination on a 2 year old child. Which one of these reflects the correct procedureA. Pulling the pinna downWhich of these statements describes the closure of the valves in a normal cardiac cycle?C. The tricuspid valve closes slightly later than the mitral valveThe direction of the blood flow through the heart is best described by which of these?B. Right atrium, right ventricle , pulmonary artery, lungs, pulmonary veins, left atrium, left ventricleDuring a cardiovascular assessment, the nurse knows that a thrill isVibration that is palpableThe mother of a 10-month- old infant tells the nurse that she has noticed that her son has becomes blue when he is crying and that this is frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?A. Tetralogy of FallotA 30 year old women with a history of mitral valve prolapse states that she has been very tired. She has started waking up at night and feel like her heart is pounding. During the assessment, the nurse palpates a thrill and lift at the fifth intercostal space midclavicular line. In the same area, the nurse auscultates a blowing, swishing sound right after S1. These finding would be most consistent withD. Mitral regurgitationDuring an assessment of a 20 year old patient with a 3 day history nausea and vomiting the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective ofDehydrationWhich of these statements is true regarding the vertebra prominens? The vertebra prominens isA. The spinous process of C7When a light is directed across the iris of a patient eye from the temporal side, the nurse is assessing forC. Presence of shadows, which may indicate glaucomaWhen examining the mouth of an older patient, the nurse recognizes which of the findings is due to the aging process?B. tongue that looks smoother in appearanceA 72 year old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in health history would beD. Have you noticed any dryness in your mouthWhile performing an assessment of the mouth, the nurse notices that the patient has a 1cm ulceration that is crusted with an elevated border and located on the outer third of lower lip. What other information would be the most important for the nurse to assess?B. When the patient first noticed lesionsThe nurse is assessing a patient history of history intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign ofA. Acquired immunodeficiency syndrome ( AIDS)