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)
... [Show More] 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 high-frequency 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
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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101. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
A) Dullness
B) Tympany
C) Resonance
D) Hyperresonance
A) Dullness
Page: 541. The liver is located in the right upper quadrant and would elicit a dull percussion note.
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102. Which structure is located in the left lower quadrant of the abdomen?
A) Liver
B) Duodenum
C) Gallbladder
D) Sigmoid colon
D) Sigmoid colon
Page: 530. The sigmoid colon is located in the left lower quadrant of the abdomen.
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103. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
A) Percuss and palpate in the lumbar region.
B) Inspect and palpate in the epigastric region.
C) Auscultate and percuss in the inguinal region.
D) Percuss and palpate the midline area above the suprapubic bone.
D) Percuss and palpate the midline area above the suprapubic bone.
Pages: 539-540. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.
104. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:
A) pulsations of the renal arteries.
B) pulsations of the inferior vena cava.
C) normal abdominal aortic pulsations.
D) increased peristalsis from a bowel obstruction.
C) normal abdominal aortic pulsations.
Pages: 538-539. Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.
105. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
A) diarrhea.
B) peritonitis.
C) laxative use.
D) gastroenteritis.
B) peritonitis.
Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
106. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
A) a loud continuous hum.
B) a peritoneal friction rub.
C) hypoactive bowel sounds.
D) hyperactive bowel sounds.
D) hyperactive bowel sounds.
Pages: 539-540. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.
107. During an abdominal assessment, the nurse would consider which of these findings as normal?
A) The presence of a bruit in the femoral area
B) A tympanic percussion note in the umbilical region
C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line
D) A dull percussion note in the left upper quadrant at the midclavicular line
B) A tympanic percussion note in the umbilical region
Pages: 539-540. Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).
108. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:
A) 1 minute.
B) 5 minutes.
C) 10 minutes.
D) 2 minutes in each quadrant.
B) 5 minutes.
Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.
109. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?
A) Obturator test
B) Test for Murphy's sign
C) Assess for rebound tenderness
D) Iliopsoas muscle test
B) Test for Murphy's sign
Page: 551. Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.
110. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition?
A) Intra-abdominal bleeding
B) Constipation
C) Umbilical hernia
D) An abdominal tumor
C) Umbilical hernia
Page: 537. The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
111. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.
A) Test for Murphy's sign.
B) Test for Blumberg's sign.
C) Test for shifting dullness.
D) Perform iliopsoas muscle test.
E) Test for fluid wave.
B) Test for Blumberg's sign.
D) Perform iliopsoas muscle test.
Pages: 543-544 | Page: 551. Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.
112. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?
A) 2
B) 3
C) 4
D) 5
D) 5
Pages: 578-579. Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.
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113. The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.
A) Symmetric joint involvement
B) Asymmetric joint involvement
C) Pain with motion of affected joints
D) Affected joints are swollen with hard, bony protuberances
E) Affected joints may have heat, redness, and swelling
B) Asymmetric joint involvement
C) Pain with motion of affected joints
D) Affected joints are swollen with hard, bony protuberances
Page: 608. In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
114. During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:
A) cranial nerve dysfunction.
B) lesion in the cerebral cortex.
C) normal changes due to aging.
D) demyelinization of nerves due to a lesion.
C) normal changes due to aging.
Page: 629. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.
115. In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be?
A) "Does your family know you are drinking every day?"
B) "Does the tremor change when you drink the alcohol?"
C) "We'll do some tests to see what is causing the tremor."
D) "You really shouldn't drink so much alcohol; it may be causing your tremor."
B) "Does the tremor change when you drink the alcohol?"
Page: 632. Intention tremor/ senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.
116. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?
A) Firm, rigid resistance to movement
B) Mild, even resistance to movement
C) Hypotonic muscles as a result of total relaxation
D) Slight pain with some directions of movement
B) Mild, even resistance to movement
Page: 637. Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.
117. When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):
A) ataxia.
B) lack of coordination.
C) negative Homans' sign.
D) positive Romberg sign.
D) positive Romberg sign.
Page: 638. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.
118. During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?
A) The nurse would not do this part of the examination because results would not be valid.
B) The nurse would perform the tests, knowing that mental status does not affect sensory ability.
C) The nurse would proceed with the explanations of each test, making sure the wife understands.
D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.
D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.
The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.
119. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?
A) Lack of reflexes
B) Normal reflexes
C) Diminished reflexes
D) Hyperactive reflexes
D) Hyperactive reflexes
Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect
120. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate?
A) These are normal findings resulting from aging.
B) These could be related to hyperthyroidism.
C) These are the result of Parkinson disease.
D) This patient should be evaluated for a cerebellar lesion.
A) These are normal findings resulting from aging.
Page: 659. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.
121. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of:
A) a great sense of humor.
B) uncooperative behavior.
C) inability to understand questions.
D) decreased level of consciousness.
D) decreased level of consciousness.
Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.
122. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
A) Cranial nerves, motor function, and sensory function
B) Deep tendon reflexes, vital signs, and coordinated movements
C) Level of consciousness, motor function, pupillary response, and vital signs
D) Mental status, deep tendon reflexes, sensory function, and pupillary response
C) Level of consciousness, motor function, pupillary response, and vital signs
Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
123. During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?
A) Injury to the right eye
B) Increased intracranial pressure
C) Test was not performed accurately
D) Normal response after a head injury
B) Increased intracranial pressure
Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.
124. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures?
A) Cerebrum
B) Cerebellum
C) Cranial nerves
D) Medulla oblongata
A) Cerebrum
Pages: 621-622 | Page: 660. The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of c [Show Less]