Health Assessment

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Question

Answer

A 35 yr old recent immigrant is being seen in clinic for complaints of cough that's associated w/rust-colored sputum, low-grade afternoon fevers, & night sweats for past 2 months. Nurse's preliminary analysis is that this patient may be suffering from:

tuberculosis

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The nurse is aware that tactile fremitus is produced by:

sounds generated from the larynx

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During auscultation of the lungs, the nurse knows that decreased breath sounds would most likely be heard:

when the bronchial tree is obstructed

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Upon examination of a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient complains of pain with breathing. These findings are consistent with:

pleural friction rub

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A male patient has come in for an examination and he states, "I think that I have the mumps". You would begin by examining the:

parotid gland

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Select the correct description of the right lung:

shorter than the left with 3 lobes

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The nurse knows that bronchovesicular breath sounds are:

expected near the major airways

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During your assessment of an infant, you note that the fontanels are depressed and sunken. You suspect:

dehydration

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During palpation of the anterior chest wall, the nurse notes a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

crepitus

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A marked prolonged expiratory phase noted during respiration is often found in patients with:

chronic obstructive pulmonary disease (COPD)

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The physician reports that a patient has a tracheal shift. The nurse is aware that this means that the patient's trachea is:

pushed to the unaffected side with a pneumothorax

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A throbbing, unilateral pain associated with nausea, vomiting, and photophobia is characteristic of:

migraine headache

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A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to Cranial Nerve _____ and proceeds with the examination by:

XI: asking the patient to shrug her shoulders against resistance

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Air passing through narrowed bronchioles would produce which of the following adventitious sounds:

wheezes

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When auscultating breath sounds, it is best to use the ____________ of the stethoscope.

diaphragm

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Your patient has a long history of chronic obstructive pulmonary disease (COPD). You are most likely to observe:

an anteroposterior: transverse diameter ratio of 1:1

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If the thyroid gland is enlarged, which of the following maneuvers is appropriate?

Listen for a bruit over the thyroid lobes.

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The pulse oximeter measures:

arterial oxygen saturation

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When inspecting the anterior chest you should assess for:

the shape and configuration of the chest wall

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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 knows that these are:

vesicular breath sounds and are normal in that location

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A normal finding when assessing the respiratory system of an elderly adult is:

decreased mobility of the chest wall

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During auscultation of breath sounds, the nurse will use the stethoscope correctly, as follows:

listen to at least one full respiration in each location

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The nurse has noted unequal chest expansion and recognizes that this occurs when:

part of the lung is obstructed or collapsed

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Some conditions have a cough with characteristic timing. The cough associated with chronic bronchitis is best described as:

productive cough for at least 3 months of the year for 2 years in a row

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A patient is assessed and found to have shallow respirations at a rate of 10 breaths per minute. This should be documented as:

hypoventilation

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Breath sounds normally heard over most of the lung fields are called:

vesicular

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A major health concern for patients with significant kyphosis is:

impaired cardiopulmonary function

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A patient presents with excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts about 1/2 to 2 hours, occurring once or twice each day. The nurse suspects:

cluster headaches

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The nurse has just completed a lymph assessment on a 60 year old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:

not palpable

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A patients incision is noted to be just above the nipple. This location can also be described as:

midclavicular

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Breath sounds normally heard over the trachea are called:

bronchial

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Tactile fremitus is assessed by:

instructing the patient to say "ninety-nine" as you palpate over the chest wall

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The nurse is aware that the four areas in the body where lymph nodes are accessible are the:

head and neck, arms, inguinal area, and axillae

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The nurse auscultates bilateral breath sounds on a client two days after surgery and notices absent breath sounds in the bases. The nurse recognizes this is most likely due to which of the following?

Atelectesis

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

a normal finding in a healthy adult

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How should the nurse monitor for the complication of subcutaneous emphysema after any type of chest surgery?

Palpate around the surgical incisional area for crepitus.

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A 65 year old patient with a history of heart failure comes to the clinic with complaints of "being awakened suddenly from sleep, with shortness of breath." You:

suspect that the patient is experiencing paroxysmal nocturnal dyspnea

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What is the underlying reason the nurse must assess an elderly client for clinical manifestations of hypoxia?

Loss of aerating surface.

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The most important technique when progressing from one ausculatory site on the chest wall to another is:

side to side comparison

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A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the:

thyroid gland

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A 19 year old college student is brought to the emergency department with a severe headache he describes as "like nothing I've ever had before". His temperature in 104 degrees F, and he has a stiff neck. What do these signs and symptoms suggest:

meningeal inflammation

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The number of each intercostal space corresponds to that of:

the rib immediately above it

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During the assessment of infants and children, the nurse measures the head circumference and compares the measure to the chest circumference. The nurse knows that the head circumference will equal the chest circumference at what age:

toddler, age 2

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During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the:

angle of Louis

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During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement:

using gentle pressure, palpate with both hands to compare the two sides

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

consists of two lobes

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A patient's thyroid is enlarged, and the nurse is preparing to auscultate the thyroid for the presence of a bruit. A bruit is a:

soft, whooshing, pulsatile sound best heard w/bell of stethoscope

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When auscultating breath sounds in an adult, you would:

use the diaphragm of the stethoscope held firmly against the chest

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During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:

coarse facial features

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A woman comes to the clinic and states, "My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse suspects:

myxedema

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