HESI Health Assessment (20232024) Real Exams Questions and Answers Test Bank

HESI HEALTH ASSESSMENT LATEST 2023/2024 TEST BANK REAL EXAM 200+QUESTIONS AND DETAILED ANSWERS |AGRADE | INCLUDES RATIONALES | ACCURATE AND VERIFIED The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatment?

A. The development of resistant strains of TB is decreased with a combination of drugs.

B. Compliance to the medication regimen is challenging but should be maintained.

C. Side effects are minimized with the use of a single medication but is less effective.

D. The treatment time is decreased from 6 months to 3 months with this standard regimen.

A Combination therapy is necessary to decrease the development of resistant strains of TB (A) and ensure treatment effectiveness. (B, C, and D) are not the rationales for multiple drug protocol for TB. The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance test (OGTT). which laboratory result should the RN assess as a normal value for the two hour postprandial result?

A. 140 mg/dl B. 160 mg/dl C. 180 mg/dl D. 200 mg/dl A The two hour postprandial level should be less than 140 mg/dl for a young adult client (B). (A, C and D) are elevated and not normal at 2 hours after ingesting the glucose solution.

After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement?

A. Position the client on the left side with a pillow placed under the costal margin.

B. Assist the client with voiding immediately after the procedure.

C. Evaluate the vital signs q10 to 20 minutes for every 2 hours after the procedure.

D. Ambulate client 3 times in the first hour with a pillow held at the abdomen.

C Vital signs should be checked every 10 to 20 minutes (C) to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side, not the left (A), with a pillow or sandbag under the costal margin and supporting the biopsy site. Voiding immediately after the procedure (B) is not the highest priority intervention after a liver biopsy.

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The client should be maintained on bedrest (D) for several hours to decrease the risk of bleeding from the biopsy site.

While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for possible interaction with an over-the-counter (OTC) decongestant.

Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply) A. Type I diabetes mellitus (DM) B. Closed angle glaucoma C. Chronic hypertension D. Rheumatoid arthritis E. Crohn's disease B Closed angle glaucoma C Chronic hypertension (B and C) are correct. OTC decongestants can increase intraocular pressure and should be avoided in clients with closed angle glaucoma (B). Decongestants can increase the heart rate and blood pressure which impact the client's management of chronic hypertension (C). Although the healthcare provider should be informed of all medications taken, (A, D, and E) are not directly affected by a decongestant.

The registered nurse (RN) is evaluating a client who presents with symptoms of gastroenteritis.

Which assessment finding should the RN report to the healthcare provider?

A. Dry mucous membranes and lips.

B. Rebound abdominal tenderness over the right lower quadrant.

C. Dizziness when the client ambulates from a sitting position.

D. Poor skin turgor over the client's wrist.

B RLQ rebound abdominal tenderness (B) may be related to acute appendicitis and should be reported to the healthcare provider. (A, C and D) are expected findings associated with gastroenteritis that are not urgent findings or life threatening.

The registered nurse (RN) reviews the new prescription, phelezine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess?

A. Consumption of any alcohol or tyramine-rich foods.

B. Complaints of nausea or vomiting.

C. Therapeutic serum drug levels.

D. Blood pressure and pulse prior to taking each dose.

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A. All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D).

Which actions should the registered nurse (RN) implement to complete an assessment for a client using an interpreter?

A. Ask close-ended questions with assistance of the interpreter.

B. Maintain eye contact with the client while listening to the translation.

C. Instruct interpreter to answer questions from the interpreter's point of view.

D. Protect the client's privacy by asking a limited number of questions.

B When completing an assessment, the RN should maintain eye cotnact with the client (B) to gather additional information from the client's nonverbal cues. (A, C, and D) do not use both verbal and nonverbal communication techniques to gather data during an assessment.

The registered nurse (RN) is interviewing a female client who states she has a persistent cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis?

A. Phlegm production and wheezing.

B. Smoking history C. Hemoptysis D. Night sweats A A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing (A). Although smoking can contribute to chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new" cough or changes in a persistent chronic cough is likely related to lung cancer (C). Night sweats (D) is a trend in fever that is often seen with tuberculosis.

The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) a. native language b. education level c. type of lifestyle d. previous medical history e. financial resources A, B, C, E

(A, B, C, and E) are correct. To ensure compliance, language (A), education (B), lifestyle (C), and financial resources (E) should be considered when preparing the client's discharge instructions about continued treatment of TB. (D) does not directly impact compliance with long term treatment of TB. The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT).

Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? a. check the pH of aspirated stomach contents obtained from the NGT b. auscultate over the epigastrium while injecting air into the NGT c. disconnect and place the end of NGT in water to see if bubbles appear d. listen for hyperactive bowel sounds in all four quadrants in the abdomen A Checking the pH of the aspirate (A) is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid. (B, C and D) are not reliable methods to ensure NGT placement in the stomach.

A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? (Select all that apply) a. Establish trust by creating a safe atmosphere for sharing. b. Share personal stories about how other clients dealt with grief. c. Help the client identify ways to adapt lifestyle to accommodate loss. d. Assure the client that their grief will last a short period of time. e. Explore ways to assist the client to make new emotional investments.

A, C, E (A, C, and E) are correct, and these interventions aid the client in maneuvering through the stages of grieving and establishing a foundation to continue life. Assisting the client in finding the support group and sharing stories of other clients can be miscontrued as a violation of HIPPA rights of other clients (B). Each client deals with grief differently, so offering a time line for grieving (D) is not an expected outcome for this client and offers false reassurance.

The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? a. high fever b. low blood pressure c. muscle rigidity d. polydipsia

D A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia) (D). (A) is indicative of an infection, not DI. (B) can be characteristic of hypovolemia, but not an initial finding of DI. Muscle rigidity (C) can be a serious manifestation of a closed head injury that requires immediate action, but is not related to DI. The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema to perform pursed-lip breathing. What is the primary reason for teaching the client this method of breathing? a. Decreases respiratory rate b. Increases O2 saturation throughout the body c. Conserves energy while ambulating d. Promotes CO2 elimination D Pursed lip breathing helps eliminate CO2 (D) by increasing positive pressure within the alveoli which makes it easier to expel air from lungs. (A, B and C) do not explain the reason for using pursed lip breathing.

The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history? a. Irritable bowel syndrome b. diverticulitis c. Crohn's disease d. ulcerative colitis D The RN should ask the client if he has a history of ulcerative colitis (D), which is characterized by these presenting symptoms. Irritable bowel (A) often includes irregular bowel movements with constipation. Diverticulitis (B) is related to constipation, bowel irregularity and cramping.

Crohn's disease (C) can cause constipation or diarrhea, abscess formation, and abdominal cramping, but tenesmus is rare.

The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? (Select all that apply) a. tachycardia b. increased blood pressure

c. rapid resolution of wheezing d. improved pulse oximetry values e. reduce fever airway inflammation C, D (C and D) are correct. Beta 2 receptor agonist agents provide immediate return of airflow and resolve wheezing (C) and improve oxygenation (D). (A and B) are side effects. (E) is not an expected response.

A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.)

A. Use simple sentences during the examination.

B. Move to another question if the client seems confused.

C. Reduce environmental distractions during the examination.

D. Allow the family to answer for the client to decrease frustration.

E. Ask questions one at a time to decrease confusion.

A, C, E Communication techniques for clients with cognitive impairments should be simple (A), without environmental distractions (C), and direct (E). (B) increases anxiety in a client, so it is important to give the client time to answer a question before moving to the next one. (D) is the family's view of the client's mental status and does not give the RN an objective view of the client's cognitive impairment.

The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess?

A. Consumption of any alcohol or tyramine-rich foods.

B. Complaints of nausea or vomiting.

C. Therapeutic serum drug levels.

D. Blood pressure and pulse prior to taking each dose.

A All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D).

A female client is recently diagnosed with Sarciodosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women?

A. African American women B. Caucasian women C. Asian women D. Hispanic women A Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown presence in relatives due to multiple genes that together to increase the susceptibility of developing the disease, which most commonly occurs in African American women and women of Northern European heritage (A). (B, C, and D) have a lower percentage of women affected by sarcoidosis than African American women.

A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first?

A. Withhold medication and report symptoms and vital signs to healthcare provider.

B. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.

C. Reassure client that the ipratropium given will alleviate the symptoms.

D. Delay administration of ipratropium until next maintenance medication is scheduled.

A Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so withholding the medication (A) until the healthcare provider is notified should be initiated to maintain client safety. If the symptoms continue and are not addressed immediately, then (B, C, and D) may place the client in imminent danger.

A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage?

A. Creatine Kinase (CK-MB) B. Serum troponin C. Myoglobin D. Ischemia modified albumin B Troponin (B) is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB (A). (C) can be elevated when there is skeletal muscle damage. (D) can be elevated nonspecifically and create false positives, so is not a reliable choice.

The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report to the healthcare provider?

A. Lower back pain B. Headache of 7 on a scale of 1 to 10

C. Blood pressure of 140/98 D. Dyspnea D A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately. (A, B, and C) are expected findings after a fall and do not require immediate notification of a healthcare provider.

While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement?

A. Monitor infusing IV fluids and any replacement blood products B. Prepare for esophagogastroduodenoscopy (EGD) C. Maintain a client on strict bedrest D. Insert a nasogastric tube (NGT) for intermittent suction A Maintaining hemodynamic stability in a client with esophageal varices can precipitate a lifethreatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products (A). The healthcare provider should be present during (B and D) in the event the client's esophageal varies rupture and bleed profusely. Bedrest (C) is not a priority at this time.

The registered nurse (RN) is caring for an older client who has been bedridden for two weeks.

Which assessment findings indicate to the RN that the client is developing a complication related to immobility?

A. Decreased pedal pulses B. Edema in upper extremities C. Loss of appetite for food D. Stiffness in right ankle joint D Stiffness in joints is an early sign of contractures and muscle atrophy (D) related to inactivity and immobility. Decreased pedal pulses (A), upper extremity (B) and a loss of appetite (C) are not directly related to immobility.

An 82-year-old client is admitted with pneumonia. Which of the following actions should be the nurse's first priority as she performs this client's admission assessment?

A. Having the client sign the admission forms B. Establishing rapport with the client C. Obtaining the necessary equipment D. Taking the client's vital signs B

The first priority of a successful physical assessment is establishing rapport with the client.

Having the client sign the admission forms, taking his vital signs, and obtaining equipment are also important but aren't the nurse's first priority in most cases.

An 86-year-old client is admitted with a diagnosis of syncope. He tells the nurse, "When I get up in the morning, I feel dizzy." The nurse replies, "You feel dizzy when you get out of bed in the morning?" What communication strategy is this nurse using?

A. Reflection B. Facilitation C. Confirmation D. Summarization A Reflection is a technique that involves repeating something the client has just said. It can help the nurse obtain more specific information. Facilitation involves using phrases that encourage the client to continue with his story. Confirmation helps clear misconceptions. Summarization restates the information that the client has given.

An occupational health nurse is performing a physical assessment on a prospective company employee. Which assessment should she perform first?

A. Vital signs B. Presence of skin lesions C. Anthropometric measurements D. Appearance D After assembling the necessary equipment, the nurse should perform the first part of the assessment-forming an initial impression of the client by observing his appearance. Vital signs should follow this initial observation. Assessment for skin lesions and anthropometric measurements should occur later in the assessment process.

A 52-year-old client is admitted with unstable angina. The nurse assigned to the client notes an irregular rhythm when assessing his pulse. To further assess the irregular pulse, the nurse knows she must determine the client's pulse deficit. Which pulses help identify pulse deficit?

A. Carotid and apical B. Apical and radial C. Radial and brachial D. Carotid and radial B When determining a pulse deficit, the nurse should palpate the radial pulse while auscultating the apical pulse. The apical pulse rate minus the radial pulse rate equals the pulse deficit. Pulse deficit isn't identified using the carotid or brachial pulses.

A 65-year-old client who underwent a right-sided thoracotomy 2 days ago complains of nausea.

The nurse performs an abdominal assessment. Which sound should she hear when percussing over dense tissue?

A. Tympany B. Dullness C. Flatness D. Resonance C When percussing over dense tissue, such as muscle, the nurse should expect to hear flatness.

Tympany is heard over an area of air collection, dullness isn't heard over organs, and resonance is a low-pitched sound heard over normal lung tissue.

A nurse is assessing the blood pressure of a client with diabetic ketoacidosis. How high should she inflate the blood pressure cuff before releasing the valve and listening for blood pressure?

A. Inflate the cuff until the radial pulse disappears, and then inflate it an additional 30 mm Hg. B. Inflate the cuff to 200 mm Hg; if you hear the sound immediately, inflate to 220 mm Hg. C. Inflate the cuff until the needle on the manometer stops bouncing.

D. Inflate the cuff until the client reports feeling a tingling sensation in his hand.

A. The nurse should neither underinflate nor overinfalte the cuff. The ideal method is to palpate the radial pulse while inflating the cuff. When the radial pulse disappears, the nurse should inflate the cuff an additional 30 mm Hg and then close the valve. The other methods of obtaining blood pressure are incorrect.

A 73-year old female client with Alzheimer's disease is admitted to the hospital with dehydration.

Her daughter, who has been caring for the client at home, verbalizes frustration that the client refuses to eat or drink. The nurse performs anthropometric arm measurements on the client, and the result is 85% if the standard. What does this result suggest?

A. Caloric deprivation B. Normalcy C. Protein malnutrition D. Caloric excess A Anthropometric arm measurements help assess nutritional status. Less than 90% of the standard indicates caloric deprivation. This result doesn't indicate a normal measurement and doesn't show caloric excess. Protein malnutrition is determined by albumin levels.

A 76-year-old client is diagnosed with iron deficiency anemia. Which finding should the nurse expect when assessing this client's nails?

A. Dark, yellowish color B. Transverse bands of white C. White patches D. Spoon shape D

Clients with iron deficiency anemia typically have spoon-shaped nails. Dark, yellowish nails occur with liver disease. White, transverse bands are associated with hypoalbuminemia. White patches on the nails may be associated with a fungal infection.

A 23-year-old client is admitted to an inpatient psychiatric unit with severe depression. To develop rapport with the client, the nurse initiates a contract. What should the contract include?

A. Expectations and responsibilities for you and the client B. A description of the therapies the client will undergo C. A prediction of the length of hospitalization D. The client's insurance and financial information A A contract with a psychiatric client should include the nurse's expectations and responsibilities as well as the client's. A description of the client's therapies, the length of hospitalization, and insurance and financial information wouldn't be included in a contract.

During an assessment, an 18-year-old female states that she uses an addictive substance. Which response by the nurse is most appropriate?

A. "How do you obtain these substances?"

B. "What substance do you use?"

C. "Does your employer know about this?"

D. "You really shouldn't do that."

B When a client identifies a history of substance abuse, the nurse should assess the risk of withdrawal, which includes determining the substance being used. Determining how the substance was obtained and asking if the client's employer knows about her behavior aren't relevant. Telling the client she really shouldn't use an additive substance is judgmental and inappropriate.

A nurse is assessing a child's visual acuity using the Snellen chart. The result is 20/50 in both eyes. Which explanation should the nurse give to the child's parent?

A. "What normal eyes see at a distance of 50 feet, your child's eyes see at a distance of 20 feet."

B. "What normal eyes see at a distance of 20 feet, your child's eyes see at a distance of 50 feet."

C. "To see what normal eyes sees at a distance of 20 feet, your child's eyes need a 50% magnification increase."

D. "Your child's eyes see 20% of what children with normal vision see at 50 feet."

A The Snellen chart measures visual acuity and provides readings such as 20/50. A person with 20/50 vision can view from 20 feet that which a person with normal vision can view from 50 feet. The other explanations are incorrect.

During an interview, a client has episodes in which she jumps abruptly from topic to topic.

Which identifies this type of speech?

A. Neologisms B. Echolalia

C. Confabulation D. Flight of ideas D A continuous flow of speech from which the client jumps abruptly from topic to topic is called flight of ideas. Neologism is the distortion or invention of words. Echolalia is the client's repetition of the interviewer's words. Confabulation is the fabrication of events to fill in for memory loss.

After making violent threats against her husband, a client who has just gone through a painful divorce is brought to the inpatient psychiatric unit by the police. Her threats of violence toward her ex-husband are most consistent with which diagnosis?

A. Schizophrenia B. Personality disorder C. Anxiety disorder D. Obsessive-compulsive disorder B Pervasive maladaptive patterns of behavior suggest a personality disorder. Schizophrenia is characterized by an impaired perception of reality. An anxiety disorder is characterized by anxiety and avoidant behavior. Obsessive-compulsive disorder involves recurrent obsessions and compulsions.

A client is admitted with excessive vomiting after eating at a buffet. To assess the client's skin turgor for signs of dehydration. The nurse should: A. Squeeze the skin on his forearm or sternum B. Palpate the skin on the dorsum of his hand C. Press on the nail beds to cause blanching D. Transilluminate the skin over the forearm A To evaluate skin turgor, the nurse should gently squeeze the skin on the forearm or sternum. The skin quickly returns to its original shape, the client's skin turgor is normal. If it returns to its original shape slowly after 30 seconds or maintains a tented position, the skin has poor turgor, which is a sign of dehydration. Palpating or transilluminating the skin doesn't detect dehydration.

Pressing on the nail beds help evaluate circulation.

A nurse notes a number of small, firm, round, raised lesions on the client's body. She should chart these findings as: A. Macules B. Pustules C. Papules D. Plaques C

Papules are small, raised, circumscribed, solid lesions. Macules are flat lesions. Pustules are small, inflamed, blister-like lesions. Plaques are broad, raised areas on the skin.

A 49-year-old client with a history of alcohol abuse is admitted with bleeding esophageal varices.

The nurse assessing him notes several small, weblike, vascular lesions on his cheeks. The nurse should chart these findings as: A. Purpura B. Telangiectases C. Angiomas D. Petechiae B Telangiectases are small, dilated vessels that form a web-like pattern. They're commonly seen on the face, especially in clients with a history of alcohol abuse. Purpura is a red or purple discoloration of the skin. Angiomas are benign tumors near the surface of the skin. Petechiae are pinpoint hemorrhages in the skin or mucous membranes.

A 65-year-old client comes to the plastic surgeon's office for a follow-up appointment after having a basal cell lesion removed from his face. When teaching the client how to inspect his skin for signs of melanoma, the nurse should tell the client to look for: A. pale patches on the skin B. skin flaking that won't go away C. black or purple irregularly shaped nodules D. flat areas of discoloration C Typically, melanomas are black or purple nodules that are irregularly shaped. Pale patches on the skin, skin flaking, and flat areas of discoloration aren't signs of melanoma.

The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit?

A. Acceptance B. Denial C. Bargaining D. Depression B. Denial The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent (A, C, and D) are stages of grief that are not being displayed by the client's spouse during this observation.

The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate?

A. Reduced pain and minimized bruising.

B. Lowering of body core temperature.

C. Increased circulation around injury.

D. Reabsorption of edema at injury.

A. Cold applications produce a topical anesthetic effect to reduce pain as well as constrict blood vessels to minimize bruising (A). Local ice over an injured area will not lower the core temperature (B). The cold pack causes vasoconstriction which reduces circulation, not (C), to traumatized tissue and limits further edema around the injury (D), but not by reabsorption of edematous fluid.

The registered nurse (RN) palpates a weak pedal pulse on the client's right foot. Which assessment findings should the RN document that is consistent with diminished peripheral circulation (Select all that apply.) A. Diminished hair on legs.

B. Bruising on extremities.

C. Skin cool to touch.

D. Capillary refill less than 3 seconds.

E. Darkened skin on extremities.

A. Diminished hair on legs C. Skin cool to touch.

Diminished hair on the legs (A) and skin that is cool to the touch (C) are symptoms of decreased arterial blood flow. (B, D, and E) are not indicators for impaired circulation.

Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock?

A. Faint pedal pulses B. Decrease in blood pressure.

C. Lethargy.

D. Slow breathing.

C. Lethargy Changes in the level of consciousness occur in the early stages of shock which decreases the perfusion to the brain which is manifested as lethargy (C). The respiratory rate increases, not (D).

(A and B) are late signs of hypovolemic shock due to cardiac compensatory measures.

The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? A. Take the medication at bedtime.

B. Report presence of increased bruising.

C. Check pulse before taking medication.

D. Rise slowly when getting out of bed or chair.

D. Rise slowly when getting out of bed or chair.

The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect of orthostatic hypotension. Instructing the client to rise from a chair or bed slowly (D) is indicated to avoid dizziness and falling. (A, B, and C) are not indicated when taking an ACE inhibitor.

The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after removal of the chest tube?

A. Prepare the client for chest x-ray at the bedside.

B. Review arterial blood gases after removal.

C. Elevate the head of the bed to 45 degrees.

D. Assist with disassembling the drainage system.

A. Prepare the client for a chest x-ray at the bedside.

A chest x-ray (A) should be performed immediately after the procedure to ensure lung expansion has been maintained after removal of the chest tube. (B) provides additional data after removal of the CT. (C) may assist the client to breathe easily, but the priority after chest tube removal is to ensure that the procedure was successful. The entire system, including the chest tube is discarded and not taken apart (D).

A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family asks the nurse what this means. Which type of fracture should the RN explain from these findings?

A. A straight fracture line that is also a simple, closed fracture.

B. A nondisplaced fracture line that wraps around the bone.

C. A complete fracture that also punctures the skin.

D. A fracture that bends or splinters part of the bone.

D. A fracture that bends or splinters part of the bone.

An incomplete fracture (D) occurs through part of the thickness of bone. A linear (A) and a spiral fracture (B) describe the direction of the fracture line. An open fracture (C) is a compound fracture that breaks through the skin.

The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify that is consistent with PUD? (Select all that apply) A. Hematemesis B. Gastric pain on an empty stomach C. Colic-like pain with fatty food ingestion D. Intolerance of spicy foods E. Diarrhea and stearrhea

A. Hematemesis B. Gastric pain on an empty stomach D. Intolerance of spicy foods (A, B and D) correct. Manifestations of PUD include hematemesis (A), gastric pain (B), and spicy food intolerance. (C) is consistent with cholecystitis (D). (E) is not consistent with PUD. A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula?

A. Over use of laxatives for bowel regularity result in loss of peristaltic tone.

B. Inflammation of the colon mucosa that causes growths that protrude into the lumen.

C. Diverticulosis is the result of a high fiber diet and sedentary lifestyle.

D. Chronic constipation causes weakening of colon wall which results in out-pouching sacs.

D. A client who has chronic constipation (D) often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the signmoid. Regular use of laxatives (A) can result in the bowel's dependency on the laxative to stimulate intestinal motility, but constipation due to lack of fiver in diet, not (C), is a predisposing factor for formation of diverticula. Growths that protrude into the colon lumen are polyps (B), which are often pre-cancerous lesions.

The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response?

A. The client cannot understand the nurse.

B. The client is uncomfortable with the nurse.

C. The client is treating the nurse with respect.

D. The client is purposefully disrespecting the nurse.

C. In some Asian cultures, it is not appropriate to look a person of authority in the eyes, so the client is being respectful bu looking down while speaking with the nurse (C). (A, B, and D) does not reflect behaviors common to Asian culture.

The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing?

A. Urine output of 40 ml/hour B. Apical pulse 100 and blood pressure 76/42.

C. Urine specific gravity of 1.001.

D. Tented skin on the dorsal surface of the hands.

A.

A decrease in urine output is a sign of dehydration. When the urine output returns to a normal range, 40 ml/hour (A), the client's kidneys are perfusing adequately and indicates the client's status is stabilizing. A blood pressure of 76/42 (B) and tented skin (D) are consistent with dehydration and possible hypovolemia, however the client's urine output is improving. Specific gravity of 1.001 is indicative of the kidney's ability to concentrate urine adequately.

An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor.

Which assessment data should the RN gather to determine if the client has a fluid volume deficit?

A. Elevated blood pressure B. Orthostatic hypotension C. Shortness of breath D. Cheyne Stocks respirations B Orthostatic hypotension (B) can be a sign of fluid volume deficit in an older adult client who has experienced severe diarrhea. (A and C) are signs of excess fluid volume. Cheyne Stocks respirations (D) is an abnormal breathing pattern often seen in a client who is near death.

A 9-year old child tells his school nurse that his eye itches and tears much more than usual.

When the nurse examines his eye, his sclera is reddened. Which eye abnormality do these signs and symptoms most suggest?

A. Cataracts B. Ptosis C. Glaucoma D. Conjunctivitis D Conjunctivitis causes redness of the eye as well as itching and increased tearing. A child would be unlikely to develop a cataract or glaucoma. Ptosis refers to a drooping eyelid.

A nurse is inspecting a 10-year-old child's pupils as part of a routine eye examination. When the nurse shines indirect light into the child's right eye, the normal response would be: A. both eyes dilate B. both eyes constrict C. the right eye constricts, and the left eye dilates D. no response B Shining a light in the right eye should cause right eye constriction (direct) and left eye constriction (consensual). The other papillary responses aren't normal and may indicate a neurologic problem.

A nurse is performing a mental health assessment of a client seeking help to control her overwhelming anxiety. During the mental health assessment, what should be the nurse's focus?

A. To state goals for care of the client

B. To determine outcomes for the patient C. To distinguish medical problems from mental health problems D. To gather information from the client D The focus of a mental health assessment should be to gather information from the client so the nurse can develop a care plan. Goals for care and client outcomes shouldn't be determined until after the assessment is complete. The mental health assessment primarily focuses on the client's mental health, not medical problems.

An 11-year-old child reports to the school nurse with an earache and sore throat. The nurse inspects the tympanic membrane using an otoscope. Which color suggests a normal eardrum? A. Pink B. White C. Gray D. red C The normal eardrum (tympanic membrane) is gray. A pink, white, or red tympanic membrane may indicate infection and effusion.

A nurse is performing an otoscopic examination on a 3-year-old child who has an earache and a fever. In which direction should the nurse pull the child's auricle to straighten the ear canal?

A. Down and forward B. Up and forward C. Up and back D. Down and back C To perform an otoscopic examination on a client age 3 or older, the nurse should pull the auricle up and back to straighten the ear canal. Pulling the auricle in other manners described may cause injury to the child's eardrum.

A mother states her daughter has been complaining for 3 days of a sore throat, which has increased in severity. The nurse palpates the girl's neck and identifies a swollen lymph node directly under the chin. Which lymph node is this?

A. Preauricular B. Submandibular C. Submental D. Supraclavicular C The submental lymph node is located directly under the chin. The preauricular lymph node is located in front of the ear. The submandibular nodes are under the mandible, and the supraclavicular nodes are above the clavicle.

A 19-year-old college student is brought to the emergency department with dyspnea and asymmetrical breathing patterns after falling down a flight of steps at a party. His admission chest X-ray shows right-sided pneumothorax. During inspection, what other characteristic of pneumothorax might the nurse observe?

A. Funnel chest B. Barrel chest C. Intercostal retractions D. Tracheal deviation D With pneumothorax, the nurse may observe intercostal retractions; with right-sided pneumothorax, deviation to the left may also be present. Funnel chest is a chest deformity. Barrel chest occurs with chronic obstructive lung disease.

After a fall from a scaffold, a 32-year-old construction worker complains of shortness of breath and has labored breathing. His admission chest X-ray reveals a small, right-sided pneumothorax.

What sound should the nurse expect when percussing over the right lung?

A. Tympany B. Dullness C. Hyperresonance D. Flatness C For a client with pneumothorax, the pleural space on the affected side is increased, which produces a hyperresonant sound on percussion. Tympanic sounds occur over air and may be heard with a large pneumothorax. Dullness is heard over a solid area, such as in pneumonia, and flatness occurs with consolidation.

A nurse is performing an admission assessment of a 63-year-old client with pneumonia. While auscultating his lungs, the nurse asks him to repeatedly say "ninety-nine." For what sound is the nurse checking? A. Bronchophony B. Egophony C. Pectoriloquy D. Crepitus A A client develops a pneumothorax after an attempted central line insertion. What breath sounds should the nurse expect to hear over the affected lung?

A. Crackles B. Rhonchi C. Diminished sounds D. Wheezes C

With pneumothorax, air movement is diminished or absent in the affect lung, so breath sounds are diminished in that area. Crackles are related to collapsed or fluid-filled alveoli. Rhonchi result from fluid in large airways. Wheezes are caused by blocked airflow.

A 63-year-old client is hospitalized in the coronary care unit after experiencing an anterior myocardial infarction (MI). As the nurse performs the initial assessment, she palpates the pulses on the top of the client's feet. What are these pulses?

A. Popliteal pulses B. Dorsalis pedis pulses C. Posterior tibial pulses D. Anterior tibial pulses B The pulses on tops of the feet are the dorsalis pedis pulses. The popliteal pulse is located behind the knee. The posterior tibial pulse is found posterior to the medial malleolus. The anterior tibial pulse is located anterior to the ankle.

A 57-year-old, obese client comes to the emergency department complaining of chest pain that developed while he was climbing the stairs. The nurse asks the client to describe his chest pain.

Which type of chest pain is most commonly associated with MI? A. Sore and aching B. Dull and stabbing C. Sharp and burning D. Tightness and pressure D The pain typically associated with an MI is characterized by tightness and pressure. The other types of pain described could be associated with an MI but are less common.

A 19-year-old client is admitted to the coronary care unit after experiencing a syncopal episode while playing basketball. When auscultating his heart sounds, the nurse hears a "lub-dub" sound.

What mechanical event in the heart is associated with the "lub" sound?

A. Closure of the mitral and aortic valves B. Closure of the tricuspid and aortic valves C. Closure of the aortic and pulmonic valves D. Closure of the mitral and tricuspid valves D The first heart sound, S1, which produces the "lub" sound, is associated with closure of the mitral and tricuspid valves. The second heart sound, S2, or the "dub" sound, is a result of closure of the aortic and pulmonic valves.

A nurse is inspecting a 58-year-old client's chest wall to locate the apical pulse. Where should the nurse look?

A. At the fifth intercostal space medial to the left midclavicular line.

B. Over the base of the heart C. Over the aortic area

D. At the third intercostal space to the left of the sternum A The apical impulse, also usually the point of maximum impulse, can be found at the fifth intercostal space medial to the left midclavicular line. The other areas are incorrect.

A nurse is assessing a 53-year-old client who's beginning to undergo menopause. Which finding is a normal change associated with menopause?

A. Breast enlargement B. Flattened nipples C. Asymmetrical areolae D. Inverted nipples B After menopause, glandular tissues atrophy and are replaced with fatty deposits. The breasts become flabbier and smaller, and the nipples flatten and become less erectile. Breast enlargement is most common during puberty and pregnancy. Asymmetrical areolae and inverted nipples may indicate a more serious breast condition.

During the examination of a 36-year-old client's right breast, the nurse palpates a lump. Which characteristic most suggests that the lump may be malignant?

A. Softness B. Mobility C. Irregular shape D. Nontender C An irregularly shaped lump in the breast suggests malignancy. A malignant mass may also be firm, tender, and not easily mobile.

A 28-year-old client asks, "When should I perform breast self examination (BSE)?" The best response from the nurse would be: A. "On the first day of your menstrual cycle each month."

B. "On the last day of your menstrual cycle each month."

C. "On the first day of every month."

D. "7 to 10 days after your menstrual cycle begins each month."

D Because certain changes take place in the breasts during the menstrual cycle, menstruating women should perform a BSE 7 to 10 days after the beginning of her cycle. The other choices aren't optimal times.

When palpating a client's breast, the nurse should use: A. The whole palm of the palpating hand B. One index finger

C. Three middle finger pads D. The pad of the thumb C The preferred method for palpating a client's breast is to use three middle finger pads and to gently rotate them around the breast, moving in concentric circles. Using the whole palm, one index finger, or the pad of the thumb doesn't allow the client to adequately feel the breast tissue and identify abnormalities.

A 47-year-old client complains of burning abdominal pain after eating at a Mexican restaurant.

Burning abdominal pain is most commonly associated with: A. Cholecystitis B. Appendicitits C. Peptic ulcer disease D. Pancreatitis C Burning abdominal pain is most commonly associated with peptic ulcer disease. Cholecystitis and pancreatitis cause stabbing abdominal pain. Appendicitis causes severe abdominal cramping.

A physician orders daily measurement of abdominal girth for a 35-year-old client with upper-GI bleeding. At which point on the abdomen should the nurse take her measurement?

A. Just below the rib cage B. Just above the pelvis C. Across the umbilicus D. At the fullest point D When measuring abdominal girth, the nurse should measure the abdomen at its fullest point.

Measuring at the other points may not accurately evaluate an increase in abdominal size.

A 27-year-old client comes to the emergency room complaining of abdominal pain. Deep palpation of the abdomen shouldn't be performed if the client: A. Has ascites B. Reports constipation C. Is ticklish D. Has abdominal rigidity D Because abdominal rigidity may indicate peritoneal inflammation, the nurse should avoid palpation because it may lead to pain or organ rupture. Performing deep palpation on a client who has ascites, is constipated, or is ticklish may be difficult, but it isn't contraindicated.

A nurse is assisting a physician with a routine pelvic examination. What lubricant should the nurse use on the speculum?

A. Water-soluble jelly

B. Petroleum jelly C. Warm water D. Mineral oil C Water should be used to lubricate the speculum before an internal vaginal examination. Other lubricants are discouraged because they can alter the results of a Pananicolaou test.

A nurse is teaching a group of fifth-grade girls about menstruation. She tells them that menses occurs every 21 to 38 days and that the duration is normally: A. 2 to 4 days B. 2 to 8 days C. 3 to 5 days D. 4 to 7 days B Although menses duration may vary, the duration in a nomrla menstrual cycle is 2 to 8 days.

A client with a urinary tract infection reports pain when the nurse percusses her back at the costovertebral angle. This finding suggests: A. A ureteral stone B. an ovarian cyst C. kidney inflammation D. bladder cancer C Pain during percussion over the costovertebral angle suggests kidney inflammation. Clients with ureteral stones, ovarian cysts, or bladder cancer more commonly complain of abdominal pain.

A school nurse is performing an annual screening on a 12-year-old student. To assess for scoliosis, the nurse should: A. Palpate for crepitus B. Measure the length of the spine from neck to waist.

C. Ask the client to bend forward at the waist D. Palpate the spinous processes C To assess for scoliosis, the nurse should inspect the spine for abnormalities while the client is bending forward at the waist. This position can make spinal deformities more apparent. The other actions don't assist with the diagnosis of scoliosis.

A 28-year-old client tells a nurse that he discovered a lump in his scrotum. Before palpating his testicles, the nurse should know that a normal testicle is: A. irregularly shaped B. Round C. Rubbery D. Nodular

C A normal testicle is oval and rubbery. An irregularly shaped or nodular testicle may indicate malignancy. A round testicle isn't normally found.

A 46-year-old construction worker comes to the clinic for his annual physical examination.

During the assessment, the nurse palpates the inguinal area for what reason?

A. To check for herniation B. To locate a pulse C. To check for a nondescended testicle D. To assess the prostate gland A The purpose of palpating a client's inguinal area during assessment is to check for herniation. The nurse wouldn't find a pulse, testicle, or prostate gland in this area.

A 62-year-old client complains of urinary hesitancy. During the assessment, the nurse palpates his prostrate gland. The nurse should know that a normal prostate gland is about the size of a: A. marble B. grape C. walnut D. peach C A normal prostate gland is about the size of a walnut. The other choices are incorrect.

After slipping in her bathroom, an 80-year-old client is brought to the emergency department with a deformed right hip and hip pain that she rates as an 8 on a scale of 1 to 10. The nurse examining her notices gross internal rotation of the right hip. Which of the following signs alerts the nurse to this assessment?

A. A misshapen pelvis B. Inward pointing of the foot C. Outward pointing of the foot D. Unequal leg lengths B With internal rotation of the hip, inward turning and pointing of the foot to a pigeon-toed position occurs. A misshapen pelvis and unequal leg length doesn't indicate rotation. Outward pointing of the toes is related to external rotation of the hip.

A 34-year-old client complains of pain and tingling in her right wrist. During the assessment, the client reports pain when the nurse flexes the wrist for 30 seconds. The nurse knows that this finding indicates:

A. a fractured wrist B. carpal tunnel syndrome C. a stroke D. paralysis B Pain or numbness in the hand or fingers that occurs when the client's wrist is flexed is called Phalen's sign. This finding is indicative of carpal tunnel syndrome. A fractured wrist would cause pain with any movement. Stroke and paralysis aren't indicated by pain with wrist flexion.

A 58-year-old client comes to the clinic for his annual physical examination. The nurse notices that the client's urine specimen has a brown appearance. What does this finding suggest?

A. Hypervolemia B. Benign prostatic hyperplasia C. Urinary tract infection D. Hematuria D A client with hematuria may have brown or bright-red urine. With hypervolemia, urine would be pale in appearance. Benign prostatic hyperplasia and urinary tract infection usually don't affect urine color.

A nurse is assessing the leg of a client who has come to the emergency department with a suspected fractured femur. To perform a quick and accurate assessment, the nurse should evaluate the affected leg for which of the following signs and symptoms? Select all that apply.

A. Pain B. Pliability C. Paresthesia D. Paralysis E. Pallor F. Pulses A, C, D, E, F To perform a swift assessment of a musculoskeletal injury, the nurse should remember the 5 P's: pain, paresthesia, paralysis, pallor and pulses. The nurse wouldn't assess pliability with a suspected fracture.

A 30-year-old client is brought to the emergency department with head injuries from a motorcycle accident. During the neurological assessment, the client displays Babinski's reflex.

The nurse knows that this finding is: A. an abnormal response B. a normal response

C. a hyperactive response D. a diminished response A Although Babinkski's reflex is a normal finding in infants and children younger than age 2, it's always an abnormal finding in adults. It wouldn't be classified as hyperactive or diminished.

During a routine physical examination, a 68-year-old client can't identify a pencil or a cotton ball when manipulating the object with his hands, keeping his eyes closed. The nurse knows that this abnormal finding indicates:

A. Apraxia B. Aphasia C. Graphesthesia D. Impaired stereognosis D The ability to identify a common object by touching and manipulating is called stereognosis. If the client has impaired stereognosis, the nurse should next test graphesthesia. Apraxia is the inability to perform coordinated movments. Aphasia is a language deficit.

A nurse is assessing the cranial nerves of a 62-year-old client who had a stroke. How should the nurse assess the function of cranial nerve (CN) VII? A. Test the client's hearing and ask him if he ever experiences dizziness or vertigo B. Test the client's ability to feel light touch on his face as well as his ability to differentiate between sharp and dull sensations on his face C. Test the client's ability to identify tastes, and observe his face for symmetry at rest and wile making facial expressions, such as smiling or frowning D. Test the client's gag reflex and ability to swallow C CN VII (the facial nerve) has sensory and motor components. The nurse should assess the sensory component by testing the client's taste perception and test the motor component by observing the function of the facial muscles. The acoustic nerve (CN VIII) is responsible for hearing and equilibrium. The trigeminal nerve (CN V) allows for differentiation of sensations on the face. The glossopharyngeal nerve (CN IX) is responsible for swallowing.

A client's muscle tone is assessed by performing: A. deep tendon reflex (DTR) testing B. Passive range-of-motion (ROM) exercises C. Romberg's test D. constructional ability testing

B Muscle tone, which represents muscular resistance to passive stretching, is assessed by performing passive ROM exercises. DTRs reflect neurologic function. Romberg's test evaluates balance. Constructitonal ability testing assesses the client's ability to perform simple tasks and use various objects.

An 84-year-old client complains of leg pain. A nurse assesses his legs and discovers an ulcerated area close to the ankle on his left leg. The nurse knows that this finding indicates: A. arterial insufficiency B. chronic venous insufficiency C. skin infection D. skin allergy B A client with chronic venous insufficiency is likely to have ulceration around the ankle. Arterial insufficiency is more likely to cause ulceration around the toes. A skin infection or allergy would be characterized by multiple areas of skin disruption, not an ulceration.

A nurse records a client's weight as 180 lb and his height as 70". What's this client's body mass index (BMI)? Round your answer to one decimal place.

BMI = weight in pounds/(height in inches x height in inches) x 703 180/(70 x 70) x 703 = 25.82 or 25.8

1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later.

Which statement is true regarding note-taking?

A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.

B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.

C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.

D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.

A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.

Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that notetaking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior.

2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement?

A) Reflection B) Facilitation C) Direct question D) Open-ended question D) Open-ended question Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.

3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of: A) talking too much.

B) using confrontation.

C) using biased or leading questions.

D) using blunt language to deal with distasteful topics.

C) using biased or leading questions.

Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do you?" implies that one answer is "better" than another. If the person wants to please someone, he or she is either forced to answer in a way corresponding to their implied values or is made to feel guilty when admitting the other answer.

4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is: A) just changing positions.

B) more comfortable in this position.

C) tired and needs a break from the interview.

D) uncomfortable talking about his son's treatment.

D) uncomfortable talking about his son's treatment.

Page: 37 Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture.

If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic.

5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?

A) Determine the communication method he prefers.

B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading.

C) Request a sign language interpreter before meeting with him to help facilitate the communication.

D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading.

A) Determine the communication method he prefers.

Pages: 40-41 The nurse should ask the deaf person the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him or her squarely and have good lighting on the nurse's face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and should supplement his or her voice with appropriate hand gestures or pantomime.

6. The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?

A) "Do you take medicine?"

B) "Do you sterilize the bottles?"

C) "Do you have nausea and vomiting?"

D) "You have been taking your medicine, haven't you?"

A) "Do you take medicine?"

Page: 46 In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time.

7. A female patient does not speak English well, and the nurse needs to choose an interpreter.

Which of the following would be the most appropriate choice?

A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies department

A) A trained interpreter Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible.

8. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply.

A) They elicit cold facts.

B) They allow for self-expression.

C) They build and enhance rapport.

D) They leave interactions neutral.

E) They call for short one- to two-word answers.

F) They are used when narrative information is needed.

B) They allow for self-expression.

C) They build and enhance rapport.

F) They are used when narrative information Page: 32 Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.

9. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply.

A) Collect the patient's data in a direct, face-to-face manner.

B) Enter all the data as the patient states it.

C) Ask the patient to wait as the nurse enters data.

D) Type the data into the computer after the narrative is fully explored.

E) Allow the patient to see the monitor during typing.

A) Collect the patient's data in a direct, face-to-face manner.

D) Type the data into the computer after the narrative is fully explored.

E) Allow the patient to see the monitor during typing.

Page: 32 The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.

10. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?

A) Ask the patient about the item and its significance.

B) Ask the patient to lock the item with other valuables in the hospital's safe.

C) Tell the patient that a family member should take valuables home.

D) No action is necessary.

A) Ask the patient about the item and its significance.

Page: 21 The nurse should inquire about the amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures.

11. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because MexicanAmericans: A) have less efficient immune systems and are often ill.

B) consider these symptoms a part of normal living, not symptoms of ill health.

C) come from Mexico and coughing is normal and healthy there.

D) are usually in a lower socioeconomic group and are more likely to be sick.

B) consider these symptoms a part of normal living, not symptoms of ill health.

Page: 27 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.

12. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief?

A) A person is able to work and produce.

B) A person is happy, stable, and feels good.

C) All aspects of the person are in perfect balance.

D) A person is able to care for others and function socially.

C) All aspects of the person are in perfect balance.

Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory.

13. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: A) germs and viruses.

B) supernatural forces.

C) eating imbalanced foods.

D) an imbalance within his or her spiritual nature.

B) supernatural forces.

Page: 21 The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective.

14. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she: A) will comply with the treatment prescribed.

B) has obviously given up her beliefs in naturalistic causes of disease.

C) may also be seeking the assistance of a shaman or medicine man.

D) will need extra help in dealing with her illness and may be experiencing a crisis of faith.

C) may also be seeking the assistance of a shaman or medicine man.

Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.

15. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: A) contact the hospital administrator about the best course of action.

B) automatically get a curandero for her because it is not culturally appropriate for her to request one.

C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.

D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.

C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.

Pages: 22-23 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).

16. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

A) All patients will behave the same way when in pain.

B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.

C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined.

D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.

B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.

Page: 25 In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.

17. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development.

B) children have spiritual needs that are direct reflections of what is occurring in their homes.

C) religious beliefs rarely affect the parents' perceptions of the illness.

D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs.

A) children have spiritual needs that are influenced by their stages of development.

Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.

18. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient?

A) "Are you of the Christian faith?"

B) "Do you want to see a medicine man?"

C) "How often do you seek help from medical providers?"

D) "What cultural or spiritual beliefs are important to you?"

D) "What cultural or spiritual beliefs are important to you?"

Page: 17. The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.

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19. When planning a cultural assessment, the nurse should include which component?

A) Family history B) Chief complaint C) Medical history D) Health-related beliefs D) Health-related beliefs Pages: 19-20. Health-related beliefs and practices are one component of a cultural assessment.

The other items reflect other aspects of the patient's history.

20. When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: A. has a history of drug abuse and therefore is not reliable.

B. provided consistent information and therefore is reliable.

C. smiled throughout interview and therefore is assumed reliable.

D. would not answer questions concerning stress and therefore is not reliable.

B. provided consistent information and therefore is reliable.

Page: 50. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.

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21. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?

A. Patient denies usual childhood illnesses.

B. Patient states he was a "very healthy" child.

C. Patient states sister had measles, but he didn't.

D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" because an illness common in the person's childhood may be unusual today (e.g., measles).

22. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response?

A. "Maybe she is just teething."

B. "I will check her ear for an ear infection."

C. "Are you sure she is really having pain?"

D. "Please describe what she is doing to indicate she is having pain."

D. "Please describe what she is doing to indicate she is having pain."

Page: 60. With a very young child, ask the parent, "How do you know the child is in pain?"

Pulling at ears alerts parent to ear pain. The statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.

23. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?

A. The child's birth weight B. The age at which he crawled C. Whether he has had the measles D. Reactions to previous hospitalizations D. Reactions to previous hospitalizations Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.

24. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?

A. It assesses how the individual is coping with life at home.

B. It determines how children are meeting developmental milestones.

C. It can identify any problems with memory the individual may be experiencing.

D. It helps to determine how a person is managing day-to-day activities.

D. It helps to determine how a person is managing day-to-day activities.

Page: 67. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.

25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?

A. "Do you wear glasses?"

B. "Are you able to dress yourself?"

C. "Do you have any thyroid problems?"

D. "How many times a day do you have a bowel movement?"

B. "Are you able to dress yourself?"

Page: 67. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.

26. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply.

A. "How much junk food does your child eat?"

B. "How many teeth has he lost, and when did he lose them?"

C. "Is he able to tie his shoelaces?"

D. "Does he take a children's vitamin?"

E. "Can he tell time?"

F. "Does he have any food allergies?"

B. "How many teeth has he lost, and when did he lose them?"

C. "Is he able to tie his shoelaces?"

E. "Can he tell time?"

Page: 61. Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.

27. During an examination, the nurse can assess mental status by which activity?

A) Examining the patient's electroencephalogram B) Observing the patient as he or she performs an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questions C) Observing the patient and inferring health or dysfunction Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.

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28. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: A) will have no decrease in any of his abilities, including response time.

B) will have difficulty on tests of remote memory because this typically decreases with age.

C) may take a little longer to respond, but his general knowledge and abilities should not have declined.

D) will have had a decrease in his response time because of language loss and a decrease in general knowledge.

C) may take a little longer to respond, but his general knowledge and abilities should not have declined.

Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and to react to it. Recent memory, which requires some processing is somewhat decreased with aging, but remote memory is not affected.

29. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination?

A) A patient's family is the best resource for information about the patient's coping skills.

B) It is usually sufficient to gather mental status information during the health history interview.

C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview.

D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.

B) It is usually sufficient to gather mental status information during the health history interview.

Page: 73. The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.

30. During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question?

A) "How do you feel today?"

B) "Would you please repeat the following words?"

C) "Have these medications had any effect on your pain?"

D) "Has this pain affected your ability to get dressed by yourself?"

A) "How do you feel today?"

Page: 74. Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.

31. During a mental status assessment, which question by the nurse would best assess a person's judgment?

A) "Do you feel that you are being watched, followed, or controlled?"

B) "Tell me about what you plan to do once you are discharged from the hospital."

C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?"

D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

B) "Tell me about what you plan to do once you are discharged from the hospital."

Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.

32. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

A) Mental status assessment diagnoses specific psychiatric disorders.

B) Mental disorders occur in response to everyday life stressors.

C) Mental status functioning is inferred through assessment of an individual's behaviors.

D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).

C) Mental status functioning is inferred through assessment of an individual's behaviors.

Page: 71. Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.

33. When performing a physical assessment, the technique the nurse will always use first is: A) palpation.

B) inspection.

C) percussion.

D) auscultation.

B) inspection.

Pages: 115-116. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.

34. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the: A) fingertips because they're more sensitive to small changes in temperature.

B) dorsal surface of the hand because the skin is thinner than on the palms.

C) ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.

D) palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.

B) dorsal surface of the hand because the skin is thinner than on the palms.

The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.

35. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?

A) Avoid palpation of reported "tender" areas because this may cause the patient pain.

B) Quickly palpate a tender area to avoid any discomfort that the patient may experience.

C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.

D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Pages: 115-116. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

36. The nurse would use bimanual palpation technique in which situation?

A) Palpating the thorax of an infant B) Palpating the kidneys and uterus C) Assessing pulsations and vibrations D) Assessing the presence of tenderness and pain B) Palpating the kidneys and uterus

Pages: 115-116. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.

37. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: A) consider this a normal finding.

B) palpate this area for an underlying mass.

C) reposition the hands and attempt to percuss in this area again.

D) consider this an abnormal finding and refer the patient for additional treatment.

A) consider this a normal finding.

Pages: 116-117. Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.

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38. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: A) auscultate over the area with a fetoscope.

B) use a goniometer to measure the pulsations.

C) use a Doppler device to check for pulsations over the area.

D) check for the presence of pulsations with a stethoscope.

C) use a Doppler device to check for pulsations over the area.

Page: 120. Doppler devices are used to augment pulse or blood pressure measurements.

Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones.

Stethoscopes are used to auscultate breath, bowel, and heart sounds.

39. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?

A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact.

B) Wash hands before and after every physical patient encounter.

C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another.

D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

B) Wash hands before and after every physical patient encounter.

Page: 120. The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.

40. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

A) When the infant is sleeping B) At the end of the examination C) Before auscultation of the thorax D) Halfway through the examination B) At the end of the examination Page: 123. Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.

41. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?

A) Auscultate the lungs and heart while the infant is still sleeping.

B) Examine the infant's hips because this procedure is uncomfortable.

C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.

D) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.

A) Auscultate the lungs and heart while the infant is still sleeping.

Pages: 122-124. When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.

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

A) An increase in body weight from younger years B) Additional deposits of fat on the thighs and lower legs C) The presence of kyphosis and flexion in the knees and hips D) A change in overall body proportion, a longer trunk, and shorter extremities C) The presence of kyphosis and flexion in the knees and hips

Page: 149. Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

43. When assessing the force, or strength, of a pulse, the nurse recalls that it: A) is usually recorded on a 0- to 2-point scale.

B) demonstrates elasticity of the vessel wall.

C) is a reflection of the heart's stroke volume.

D) reflects the blood volume in the arteries during diastole.

C) is a reflection of the heart's stroke volume.

Page: 134. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.

44. When assessing the quality of a patient's pain, the nurse should ask which question?

A) "When did the pain start?"

B) "Is the pain a stabbing pain?"

C) "Is it a sharp pain or dull pain?"

D) "What does your pain feel like?"

D) "What does your pain feel like?"

Page: 164. To assess the quality of a person's pain, have the patient describe the pain in his or her own words.

45. The nurse is providing care for a 68-year-old woman who is complaining of constipation.

What concern exists regarding her nutritional status?

A) The absorption of nutrients may be impaired.

B) The constipation may represent a food allergy.

C) She may need emergency surgery for the problem.

D) The gastrointestinal problem will increase her caloric demand.

A) The absorption of nutrients may be impaired.

Page: 182. Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption. The other responses are not correct.

46. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

A) Certain drugs can affect the metabolism of nutrients.

B) The nurse needs to assess the patient for allergic reactions.

C) Medications need to be documented on the record for the physician's review.

D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

A) Certain drugs can affect the metabolism of nutrients.

Page: 183 Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.

47. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors is most likely to affect the nutritional status of an elderly person?

A) Increase in taste and smell B) Living alone on a fixed income C) Change in cardiovascular status D) Increase in gastrointestinal motility and absorption B) Living alone on a fixed income Page: 176. Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an elderly person's nutritional status.

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48. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember?

A) These measurements are no longer necessary for the elderly.

B) Derived weight measures may be difficult to interpret because of wide ranges of normal.

C) These measurements may not be accurate because of changes in skin and fat distribution.

D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.

C) These measurements may not be accurate because of changes in skin and fat distribution.

Page: 191

Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to obtain and interpret in older adults because of sagging skin, changes in fat distribution, and declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity in the elderly.

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49. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation?

A) Changes in fat distribution will affect the waist-to-hip ratio.

B) Height measurements may not be accurate because of changes in bone.

C) Declining muscle mass will affect the triceps skinfold measure.

D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.

B) Height measurements may not be accurate because of changes in bone.

Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.

50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include: A) slowed gastrointestinal motility.

B) hyperstimulation of the salivary glands.

C) an increased sensitivity to spicy and aromatic foods.

D) decreased gastrointestinal absorption causing esophageal reflux.

A) slowed gastrointestinal motility.

Page: 176. Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.

51. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A) support systems.

B) circulatory status.

C) socioeconomic status.

D) psychological wellness.

B) circulatory status.

Page: 211. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

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

A) Color variation B) Border regularity C) Symmetry of lesions D) Diameter less than 6 mm A) Color variation Pages: 212-213. Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

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

A) Smooth mucous membranes and lips B) Dry mucous membranes and cracked lips C) Pale mucous membranes D) White patches on the mucous membranes B) Dry mucous membranes and cracked lips Page: 215. With dehydration, mucous membranes look dry and lips look parched and cracked.

The other responses are not found in dehydration.

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

A) Anasarca B) Scleroderma C) Pedal erythema D) Clubbing of the nails D) Clubbing of the nails Pages: 217-218. Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

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

A) Severe obesity B) Childhood growth spurts C) Severe dehydration D) Connective tissue disorders such as scleroderma C) Severe dehydration Page: 215. Decreased skin turgor is associated with severe dehydration or extreme weight loss.

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56. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: A) tell the patient to watch the lesion and report back in 2 months.

B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. C) ask additional questions regarding environmental irritants that may have caused this condition.

D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.

B) refer the patient because of the suspicion of melanoma on the basis of her symptoms.

The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.

57. The nurse is assessing for clubbing of the fingernails and would expect to find: A) a nail base that is firm and slightly tender.

B) curved nails with a convex profile and ridges across the nail.

C) a nail base that feels spongy with an angle of the nail base of 150 degrees.

D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.

D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.

Pages: 217-218. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

58. A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails?

A) Splinter hemorrhages B) Paronychia C) Pitting D) Beau lines C) Pitting Pages: 248-250. Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.

59. The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?

A) Tachycardia B) Constipation C) Rapid dyspnea D) Atrophied nodular thyroid A) Tachycardia Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland.

Dyspnea and constipation are not findings associated with hyperthyroidism.

60. During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings?

A) Positive Macewen sign B) Premature closure of the sagittal suture C) Headache, vertigo, tinnitus, and deafness D) Elongated head with heavy eyebrow ridge C) Headache, vertigo, tinnitus, and deafness Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.

61. A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: A) cachexia.

B) Parkinson's syndrome.

C) myxedema.

D) scleroderma.

C) myxedema.

Pages: 276-277. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.

62. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is: A) pulled to the affected side.

B) pushed to the unaffected side.

C) pulled downward.

D) pulled downward in a rhythmic pattern.

B) pushed to the unaffected side.

Pages: 262-263. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

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63. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?

A) Rickets B) Dehydration C) Mental retardation D) Increased intracranial pressure B) Dehydration

Pages: 265-266. Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.

64. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: A) allergies.

B) a sinus infection.

C) nasal congestion.

D) an upper respiratory infection.

A) allergies.

Page: 275. Chronic allergies often develop chronic facial characteristics. These include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.

65. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: A) "Vision is not totally developed until 2 years of age."

B) "Infants develop the ability to focus on an object at around 8 months."

C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object."

D) "Most infants have uncoordinated eye movements for the first year of life."

C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object."

Page: 284. Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously.

66. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

A) A decrease in tear production B) Unequal pupillary constriction in response to light C) The presence of arcus senilis seen around the cornea D) Loss of the outer hair on the eyebrows due to a decrease in hair follicles B) Unequal pupillary constriction in response to light

Pages: 305-308. Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

67. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: A) check for the presence of exophthalmos.

B) suspect that the patient has hyperthyroidism.

C) ask the patient if he or she has a history of heart failure.

D) assess for blepharitis because this is often associated with periorbital edema.

C) ask the patient if he or she has a history of heart failure.

Page: 312. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

68. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: A) loss of central vision.

B) shadow or diminished vision in one quadrant or one half of the visual field.

C) loss of peripheral vision.

D) sudden loss of pupillary constriction and accommodation.

B) shadow or diminished vision in one quadrant or one half of the visual field.

Page: 316. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

69. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren.

On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: A) she may have macular degeneration.

B) her vision is normal for someone her age.

C) she has the beginning stages of cataract formation.

D) she has increased intraocular pressure or glaucoma.

A) she may have macular degeneration.

Page: 285. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.

70. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: A) retinal detachment.

B) diabetic retinopathy.

C) acute-angle glaucoma.

D) increased intracranial pressure.

D) increased intracranial pressure.

Pages: 319-320. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.

71. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply.

A) The patient may experience sensitivity to light, nausea, and halos around lights.

B) The patient experiences tunnel vision in late stages.

C) Immediate treatment is needed.

D) Vision loss begins with peripheral vision.

E) It causes sudden attacks of increased pressure that cause blurred vision.

F) There are virtually no symptoms.

B) The patient experiences tunnel vision in late stages.

D) Vision loss begins with peripheral vision.

F) There are virtually no symptoms.

Pages: 308-309. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

72. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

A) "Do you ever notice ringing or crackling in your ears?"

B) "When was the last time you had your hearing checked?"

C) "Have you ever been told you have any type of hearing loss?"

D) "Was there any relationship between the ear pain and the discharge you mentioned?"

D) "Was there any relationship between the ear pain and the discharge you mentioned?"

Pages: 327-328. Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

73. The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding?

A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membrane A) A high-tone frequency loss Pages: 337-338. A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.

74. During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates: A) vertigo.

B) pruritus.

C) tinnitus.

D) cholesteatoma.

C) tinnitus.

Pages: 328-329. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

75. The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply.

A) Hearing loss related to aging begins in the mid 40s.

B) The progression is slow.

C) The aging person has low-frequency tone loss.

D) The aging person may find it harder to hear consonants than vowels.

E) Sounds may be garbled and difficult to localize.

F) Hearing loss reflects nerve degeneration of the middle ear.

B) The progression is slow.

D) The aging person may find it harder to hear consonants than vowels.

E) Sounds may be garbled and difficult to localize.

Page: 326. Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a highfrequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.

76. When assessing a patient's lungs, the nurse recalls that the left lung: A) consists of two lobes.

B) is divided by the horizontal fissure.

C) consists primarily of an upper lobe on the posterior chest.

D) is shorter than the right lung because of the underlying stomach.

A) consists of two lobes.

Pages: 413-414. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.

77. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: A) adventitious sounds and limited chest expansion.

B) increased tactile fremitus and dull percussion tones.

C) muffled voice sounds and symmetrical tactile fremitus.

D) absent voice sounds and hyperresonant percussion tones.

C) muffled voice sounds and symmetrical tactile fremitus.

Pages: 429-430. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

78. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?

A) Obtain a detailed history of the patient's allergies and history of asthma.

B) Tell the patient to sleep on his or her right side to facilitate ease of respirations.

C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.

D) Assure the patient that this is normal and will probably resolve within the next week.

C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.

Pages: 419-420. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

79. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

A) Between the scapulae B) Third intercostal space, MCL C) Fifth intercostal space, MAL D) Over the lower lobes, posterior side A) Between the scapulae Page: 424. Normally, fremitus is most prominent between the scapulae and around the sternum.

These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.

80. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate.

Which statement by the graduate nurse reflects a correct understanding of tactile fremitus?

"Tactile fremitus: A) is caused by moisture in the alveoli."

B) indicates that there is air in the subcutaneous tissues."

C) is caused by sounds generated from the larynx."

D) reflects the blood flow through the pulmonary arteries."

C) is caused by sounds generated from the larynx."

Pages: 422-423. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

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

The nurse interprets that these are: A) sounds normally auscultated over the trachea.

B) bronchial breath sounds and are normal in that location.

C) vesicular breath sounds and are normal in that location.

D) bronchovesicular breath sounds and are normal in that location.

C) vesicular breath sounds and are normal in that location.

Pages: 428-429. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.

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

B) tympany.

C) resonance.

D) hyperresonance.

A) dullness.

Pages: 424-425. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

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83. The nurse knows that auscultation of fine crackles would most likely be noticed in: A) a healthy 5-year-old child.

B) a pregnant woman.

C) the immediate newborn period.

D) association with a pneumothorax.

C) the immediate newborn period.

Pages: 436-437. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

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

A) Airway obstruction B) Emphysema C) Pulmonary consolidation D) Asthma

C) Pulmonary consolidation Page: 446. Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.

85. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

A) Wheezes B) Bronchial sounds C) Bronchophony D) Whispered pectoriloquy A) Wheezes Page: 445. Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

86. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: A) asthma.

B) atelectasis.

C) lobar pneumonia.

D) heart failure.

A) asthma.

Page: 451. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.

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87. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?

A) Listen to at least one full respiration in each location.

B) Listen as the patient inhales and then go to the next site during exhalation.

C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds.

D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.

A) Listen to at least one full respiration in each location.

Pages: 426-427. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.

88. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: A) tactile fremitus.

B) crepitus.

C) friction rub.

D) adventitious sounds.

B) crepitus.

Page: 424. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

89. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: A) atelectatic crackles, and that they are not pathologic.

B) fine crackles, and that they may be a sign of pneumonia.

C) vesicular breath sounds.

D) fine wheezes.

A) atelectatic crackles, and that they are not pathologic.

Pages: 429-430. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

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90. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.

A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice.

B) As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly.

C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said.

D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound.

E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.

A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice.

C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said.

D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound.

Page: 446. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

91. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: A) a valvular disorder.

B) blood flow turbulence.

C) fluid volume overload.

D) ventricular hypertrophy.

B) blood flow turbulence.

Page: 471. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present.

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

A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular line D) Fifth left intercostal space at the midclavicular line Pages: 473-474. The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.

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93. The nurse is preparing to auscultate for heart sounds. Which technique is correct?

A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.

B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest.

D) Listen for all possible sounds at a time at each specified area.

B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

Pages: 475-476. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.

94. The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse?

A) It is palpable in all adults.

B) It occurs with the onset of diastole.

C) Its location may be indicative of heart size.

D) It should normally be palpable in the anterior axillary line.

C) Its location may be indicative of heart size.

Page: 473 | Page: 492. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.

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

A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Pages: 504-505. Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

96. During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema.

B) early clubbing.

C) symmetry of the fingers.

D) insufficient capillary refill.

B) early clubbing.

Page: 506. The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

97. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: A) check for the presence of claudication.

B) refer the individual for further evaluation.

C) consider this a normal finding and proceed with the peripheral vascular evaluation.

D) ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

C) consider this a normal finding and proceed with the peripheral vascular evaluation.

Pages: 506-507. It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.

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98. The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate?

A) Have the patient assume a prone position.

B) Ask the patient to bend his or her knees to the side in a froglike position.

C) Press firmly against the bone with the patient in a semi-Fowler position.

D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.

B) Regular "lub, dub" pattern Pages: 510-511. To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.

99. When using a Doppler ultrasonic stethoscope, the nurse recognizes arterial flow when which sound is heard?

A) Low humming sound B) Regular "lub, dub" pattern

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C) Swishing, whooshing sound D) Steady, even, flowing sound C) Swishing, whooshing sound Pages: 515-516. When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

100. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse?

A) Bounding B) Normal C) Weak D) Absent B) Normal Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

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