B
B) Regular "lub, dub" pattern
C) Swishing, whooshing sound
D) Steady, even, flowing sound
C) Swishing, whooshing sound
Pages: 515-516. When using
... [Show More] 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) Cerebrumuctures are not responsible for a person's level of consciousness. [Show Less]