Midterm/ Final Exam: NR 509 / NR509 (Latest
2023/2024) Advanced Physical Assessment Quiz Bank |
Questions and Verified Answers with Rationales |
Chambe... [Show More] rlain College
A patient has been diagnosed with venous stasis. Which of these findings would the nurse most
likely observe?
a. Unilateral cool foot
b. Thin, shiny, atrophic skin
c. Pallor of the toes and cyanosis of the nail beds
d. Brownish discoloration to the skin of the lower leg
Answer: D
A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a
by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral
coolness are all signs associated with arterial problems.
The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these
actions would be most appropriate?
a. The patient is asked to assume a prone position.
b. The patient is asked to bend his or her knees to the side in a froglike position.
c. The nurse firmly presses against the bone with the patient in a semi-Fowler position.
d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is
extremely difficult.
Answer: B
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.
When auscultating over a patient's femoral arteries, the nurse notices the presence of a bruit on
the left side. The nurse knows that bruits:
a. Are often associated with venous disease.
b. Occur in the presence of lymphadenopathy.
c. In the femoral arteries are caused by hypermetabolic states.
d. Occur with turbulent blood flow, indicating partial occlusion.
Answer: D
A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other
responses are not correct.
. How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
a. 1+/0-4+
b. 3+/0-4+
c. 4+/0-4+
d. Brawny edema
Answer: A
If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe).
Brawny edema appears as nonpitting edema and feels hard to the touch.
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no
edema. Based on these findings, the nurse recalls that:
a. Nonpitting, hard edema occurs with lymphatic obstruction.
b. Alterations in arterial function will cause edema. c. Phlebitis of a superficial vein will cause
bilateral edema. d. Long-standing arterial obstruction will cause pitting edema.
Answer: A
Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction.
With these factors, the edema is nonpitting and feels hard to the touch (brawny edema).
The sac that surrounds and protects the heart is called the:
a. Pericardium.
b. Myocardium.
c. Endocardium.
d. Pleural space.
Answer: A
The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It
has two layers that contain a few milliliters of serous pericardial fluid.
The direction of blood flow through the heart is best described by which of these?
a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle
b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle
c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava
d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle
Answer: B
Returning blood from the body empties into the right atrium and flows into the right ventricle
and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it
is then returned to the left atrium through the pulmonary vein. The blood goes from there to the
left ventricle and then out to the body through the aorta.
3. The nurse is reviewing the anatomy and physiologic functioning of the heart. Which
statement best describes what is meant by atrial kick?
a. The atria contract during systole and attempt to push against closed valves.
b. Contraction of the atria at the beginning of diastole can be felt as a palpitation.
c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.
d. The atria contract toward the end of diastole and push the remaining blood into the ventricles.
Answer: D
Toward the end of diastole, the atria contract and push the last amount of blood (approximately
25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial
systole, or sometimes the atrial kick.
4. When listening to heart sounds, the nurse knows the valve closures that can be heard best at
the base of the heart are:
a. Mitral and tricuspid. b. Tricuspid and aortic. c. Aortic and pulmonic. d. Mitral and pulmonic.
Answer: C
The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic)
valves and signals the end of systole. Although it is heard over all the precordium, the S2 is
loudest at the base of the heart.
5. Which of these statements describes the closure of the valves in a normal cardiac cycle?
a. The aortic valve closes slightly before the tricuspid valve.
b. The pulmonic valve closes slightly before the aortic valve.
c. The tricuspid valve closes slightly later than the mitral valve. [Show Less]
