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NURS3020 Health Assessment

Week 3 Quiz

• Question 1 When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

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Answers: a. Observed in patients with kyphosis.

b. Indicative of pectus excavatum.

c. A normal finding in a healthy adult.

d. An expected finding in a patient with a barrel chest.

• Question 2 When assessing a patient’s lungs, the nurse recalls that the left lung:

Answers: a. Consists of two lobes.

b. Is divided by the horizontal fissure.

c. Primarily consists of an upper lobe on the posterior chest.

d. Is shorter than the right lung because of the underlying stomach.

Question 3 The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison.

Answers: a. Side-to-side

b. Top-to-bottom

c. Posterior-to-anterior

d. Interspace-by-interspace

• Question 4 When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:

Answers: a. Normally auscultated over the trachea.

b. Bronchial breath sounds and normal in that location.

c. Vesicular breath sounds and normal in that location.

d. Bronchovesicular breath sounds and normal in that location.

• Question 5 The direction of blood flow through the heart is best described by which of these? Answers: 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

• Question 6 A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. “I’ll be sleeping great, and then I wake up and feel like I can’t get my breath.” The nurse’s best response to this would be:

Answers: a. “When was your last electrocardiogram?”

b. “It’s probably because it’s been so hot at night.”

c. “Do you have any history of problems with your heart?”

d. “Have you had a recent sinus infection or upper respiratory infection?”

• Question 7 In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history?

Answers: a. Family history, hypertension, stress, and age

b. Personality type, high cholesterol, diabetes, and smoking

c. Smoking, hypertension, obesity, diabetes, and high cholesterol

d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol

• Question 8 The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?

Answers: a. Infant’s sleeping position

b. Sibling history of eating disorders

c. Amount of background noise when eating

d. Presence of dyspnea or diaphoresis when sucking

• Question 9 In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

Answers: a. Palpate the artery in the upper one third of the neck.

b. Listen with the bell of the stethoscope to assess for bruits.

c. Simultaneously palpate both arteries to compare amplitude.

d. Instruct the patient to take slow deep breaths during auscultation.

• Question 10 Which statement is true regarding the arterial system?

Answers: a. Arteries are large-diameter vessels.

b. The arterial system is a high-pressure system.

c. The walls of arteries are thinner than those of the veins.

d. Arteries can greatly expand to accommodate a large blood volume increase.

• Question 11 The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.

Answers: a. Ulnar

b. Radial

c. Brachial

d. Deep palmar

• Question 12 The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?

Answers: a. Behind the knee

b. Over the lateral malleolus

c. In the groove behind the medial malleolus

d. Lateral to the extensor tendon of the great toe

• Question 13 The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?

Answers: a. “Lymph flow is propelled by the contraction of the heart.”

b. “The flow of lymph is slow, compared with that of the blood.”

c. “One of the functions of the lymph is to absorb lipids from the biliary tract.”

d. “Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.”

• Question 14 When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?

Answers: a. Assess the patient’s abdomen, and notice any tenderness.

b. Carefully assess the cervical lymph nodes, and check for any enlargement.

c. Ask additional health history questions regarding any recent ear infections or sore throats.

d. Examine the patient’s lower arm and hand, and check for the presence of infection or lesions.

• Question 15 A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?

Answers: a. Hard and fixed cervical nodes

b. Enlarged and tender inguinal nodes

c. Bilateral enlargement of the popliteal nodes

d. Pelletlike nodes in the supraclavicular region

• Question 16 The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?

Answers: a. Excessive swelling of the lymph nodes

b. Presence of palpable lymph nodes

c. No palpable nodes because of the immature immune system of a child

d. Fewer numbers and a smaller size of lymph nodes compared with those of an adult

• Question 17 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?

Answers: 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

• Question 18 A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:

Answers: a. Claudication.

b. Sore muscles.

c. Muscle cramps.

d. Venous insufficiency.

• Question 19 A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

Answers: 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

• Question 20 The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?

Answers: 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.

• Question 21 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:

Answers: 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.

• Question 22 The sac that surrounds and protects the heart is called the:

Answers: a. Pericardium.

b. Myocardium.

c. Endocardium.

d. Pleural space.

• Question 23 During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:

Answers: a. Costal angle.

b. Sternal angle.

c. Xiphoid process.

d. Suprasternal notch.

• Question 24 During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

Answers: a. Adventitious sounds and limited chest expansion.

b. Increased tactile fremitus and dull percussion tones.

c. Muffled voice sounds and symmetric tactile fremitus.

d. Absent voice sounds and hyperresonant percussion tones.

• Question 25 The primary muscles of respiration include the:

Answers: a. Diaphragm and intercostals.

b. Sternomastoids and scaleni.

c. Trapezii and rectus abdominis.

d. External obliques and pectoralis major.

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