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WorksheetsHEALTH ASSESSMENT (LABORATORY)- SEMI- FINAL
Total questions: 100
Worksheet time: 34mins
What landmarks should be used on the anterior chest?
(a)
(a) is the process of using low-energy X-rays to examine the human breast for diagnosis and screening.
(a) is a physical examination of the breast done by a health professional.
(a) is the abnormal transmission of sounds from the lungs or bronchi.
(a) are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.
(a) is an abnormally slow breathing rate.
(a) is a condition that refers to rapid breathing.
(a) is an abnormal pattern of breathing characterized by groups of regular deep inspirations followed by regular or irregular periods of apnea.
(a) are the blood vessels that carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart.
(a) are small blood vessels that form the connection between the arterioles and venules and allow the circulatory system to maintain the vital equilibrium between the vascular and interstitial spaces.
What landmarks should be used posterior chest?
(a)
What landmarks should be used on the lateral chest?
(a)
The major artery that supplies blood to the arm is the:
Ulnar artery
Brachial artery
Posterior artery
Radial artery
The popliteal artery can be palpated at the:
Great toe
Knee
Inguinal ligament
Ankle
The posterior tibial pulse can be palpated at the:
Ankle
Knee
Great toe
Inguinal ligament
Stridor is a high-pitched, inspiratory crowing sound commonly associated with:
upper airway obstruction.
congestive heart failure.
pneumothorax.
atelectasis.
Percussion of the chest is:
helpful only in identifying surface alterations of lung tissue.
useful technique for identifying small lesions in lung tissue.
is not influenced by the overlying chest muscle and fat tissue.
normal if a dull note is elicited.
Which of the following pairs correctly expresses the relationship to the lobes of the lungs and their anatomic position?
Upper lobes—posterior chest
Lower lobes—posterior chest
Upper lobes—lateral chest
Lower lobes—anterior chest
During the chest assessment of a patient, which reference line does the nurse note on the posterior chest wall?
The midaxillary line
The midclavicular line
The midsternal line
The midspinal line
The nurse is assessing the bronchial breath sounds of a patient. Where should the nurse place the stethoscope?
Anterior near the upper sternum
Posterior between the scapulae
Over the peripheral lung fields
Over the trachea and the larynx
How deep can a percussion of the chest penetrate?
11 to 13 cm
5 to 7 cm
9 to 11 cm
7 to 9 cm
What should the nurse expect to assess when auscultating the lung sounds of a patient with heart failure?
Crackles in the lung bases
Crackles over upper lobes
Occasional wheezing
Bilateral expiratory wheezing
What is the main function of the respiratory system?
It helps in the production of carbon dioxide.
It helps in oxygen utilization.
It helps in the movement of air in and out of the chest.
It helps in the trapping of energy.
The nurse is assessing the thorax and lungs of an infant. Which assessment finding needs further investigation?
The respiration causes marked retraction of the sternum.
The chest wall is thin, with prominent ribs and xiphoid.
The chest circumference is 2 cm smaller than the head.
The anteroposterior and transverse diameters are equal.
The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's
pectus thorax
pectus excavatum
pectus carinatum
pectus diaphragm
The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by
asking the client to exhale forcefully and hold his breath
asking the client to take a deep breath and hold it
percussing downward until the tone changes to resonance
percussing upward from the base of the lungs
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
auscultate from the base of the lungs to the apices
place the bell on the stethoscope firmly on the posterior chest wall
ask the client to breath normally through her nose
ask the client to breathe deeply through her mouth
While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to:
repeat the letter "E."
whisper the phrase " 1 2 3"
repeat the phrase "ninety-nine"
repeat the letter "A"
A nurse auscultates low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time?
Ask the patient to cough and repeat auscultation.
Auscultate the posterior thorax for vocal sounds.
Percuss the posterior thorax for tone.
Palpate the posterior thorax for vocal fremitus.
A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patient's lungs?
Bronchial breath sounds heard over the bronchi
Vesicular breath sounds heard in peripheral lung fields
Bronchovesicular breath sounds heard over the apices
Rhonchi heard over the main bronchi
On inspection, a nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate?
Increased vocal fremitus on palpation
Dull tones heard on percussion
Complaint of sharp chest pain on inspiration
Decreased breath sounds on auscultation
The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds?
Vesicular
Stridor
Bronchovesicular
Coarse crackles
When auscultating the chest of an older patient in respiratory distress, it is best to:
Begin listening at the lung bases
Begin listening at the apices
Begin listening on the anterior chest
Ask the patient to breathe through the nose with the mouth closed.
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
Behind the knee
Over the lateral malleolus
Lateral to the extensor tendon of the great toe
In the groove behind the medial malleolus
The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?
"The flow of lymph is slow, compared with that of the blood."
"Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream."
"One of the functions of the lymph is to absorb lipids from the biliary tract."
Lymph flow is propelled by the contraction of the heart."
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?
Presence of palpable lymph nodes
Excessive swelling of the lymph nodes
Fewer numbers and a smaller size of lymph nodes compared with those of an adult
No palpable nodes because of the immature immune system of a child
Which assessment finding of the respiratory system does the nurse interpret as abnormal
Bronchial breath sounds in the lower lung fields
Resonance (to percussion) over the lung bases
Symmetric chest expansion and contraction
Inspiratory chest expansion of 1 inch
When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?
Check for calf pain.
Auscultate the site for a bruit.
Document the finding.
Check capillary refill in the toes.
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:
Check for the presence of claudication.
Refer the individual for further evaluation.
Consider this finding as normal, and proceed with the peripheral vascular evaluation.
Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n)
Absent
Bounding
Weak, thready
Normal
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
To evaluate the adequacy of capillary patency before venous blood draws
To evaluate the adequacy of collateral circulation before cannulating the radial artery
To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
To measure the rate of lymphatic drainage
The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate?
The patient is asked to bend his or her knees to the side in a froglike position.
The nurse firmly presses against the bone with the patient in a semi-Fowler position.
The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.
The patient is asked to assume a prone 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:
In the femoral arteries are caused by hypermetabolic states.
Occur in the presence of lymphadenopathy.
Occur with turbulent blood flow, indicating partial occlusion.
Are often associated with venous disease.
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?
Normal
Bounding
Weak
Absent
Edema of the legs 4+ means:
Deep pitting , leg looks swollen.
Very deep pitting , indentation lasts a long time.
Mild pitting, indentation subsides rapidly.
Moderate pitting, no obvious swelling of the leg.
The proper sequence of physical examination/ assessment techniques for abdomen is as follows:
Auscultation, inspection, palpation, percussion
Palpation, percussion, auscultation, inspection
Inspection, palpation, percussion, auscultation
Inspection, auscultation, percussion, palpation
Bowel sounds are always normally present in which quadrant of the abdomen?
RUQ
RLQ
LLQ
LUQ
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the clients:
Right upper quadrant
Right lower quadrant
Left lower quadrant
Left upper quadrant
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the:
Right upper quadrant
Right lower quadrant
Left lower quadrant
Left upper quadrant
To palpate for tenderness of an adult client’s appendix, the nurse should begin the abdominal assessment at the clients:
Right upper quadrant
Right lower quadrant
Left lower quadrant
Left upper quadrant
During auscultation of breath sounds, the nurse should use the stethoscope correctly, in:
Listening to at least one full respiration in each location
Listening as the patient inhales and then going to the next site during exhalation
If the patient is modest, listening to sounds over his or her clothing or hospital gown
Instructing the patient to breathe in and out rapidly while listening to the breath sounds
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:
Crepitus.
Tactile fremitus.
Friction rub.
Adventitious sounds.
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:
Fine wheezes.
Vesicular breath sounds.
Fine crackles and may be a sign of pneumonia.
Atelectatic crackles that do not have a pathologic cause.
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? EXCEPT?
As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine."
As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound.
When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.
Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice.
During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the:
sternal angle.
costal angle.
xiphoid process.
ENUMERATE THE PHYSICAL ASSESSMENT TECHNIQUE OF BREAST
(a)
Located within the hypodermis of the breast anterior to the pectoral muscles
(a)
Nurse Janine is going to perform an abdominal examination to Mr. Sherlock who was admitted due to on and off pain since yesterday. How will you position Mr. Sherlock prior to procedure ?
Prone
Lying on back
Downward
Supine with knees flexed
The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse's best action would be to:
consider this a normal finding.
monitor the infant's respiratory rate and rhythm.
notify the physician.
suspect a pneumothorax.
The best time to do a monthly self-breast exam is about (a) after your period starts
(a) Is when your child's breastbone is pressed inwards and they have a dip between their ribs.
(a) (dimpling of the skin resembling an orange peel) occurs due to cutaenous lymphatic oedema. The dimples represent tethering of the swollen skin to hair follicles and sweat glands.
(a) are small glands around the nipples on the areola.
When assessing whispered pectoriloquy, what would the nurse instruct the client to do?
Say the letter “e” until instructed to stop.
Say the number “ninety-nine.”
Cough each time the stethoscope is moved.
Softly repeat the words “one-two-three.”
When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces?
Suprasternal notch
Scapula
Sternal angle
Sternal border
The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What would the nurse expect to hear when auscultating the lungs of this client?
Decreased breath sounds
Sibilant wheeze
Friction rub
Stridor
A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status?
The client will have greatly increased respiratory effort.
The client will respond negatively to increased stimuli.
The client will exhibit Cheyne–Stokes respirations.
The client will have a loss of involuntary respiratory control.
During the health interview, a client tells the nurse that he “can't breathe all that well” at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for what health problem?
Heart failure
Tuberculosis
Pneumonia
Bronchitis
A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client's sputum?
White or cream-colored
Pink and frothy
Yellowish and foul-smelling
Rust-tinged
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would suspect the presence of which condition?
Pneumonia
Chronic obstructive pulmonary disease
Pleural effusion
Heart failure
The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. How would the nurse document this finding?
Normal expansion
Limited expansion
Hypoexpansion
Hyperexpansion
A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following?
Dullness
Hyperresonance
Resonance
Tympany
While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. What action would the nurse do first?
Auscultate for egophony.
Refer the client for further medical evaluation.
Have the client cough, then listen again
Perform bronchophony.
The nurse is assessing a client's breasts. When assessing the area of the breast most vulnerable to breast cancer, where should the nurse assess?
Upper inner quadrant
Upper outer quadrant
Lower inner quadrant
Lower outer quadrant
During a prenatal class, a participant says that she was told that her breasts are not large enough to breast-feed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which variable?
Amount of glandular tissue
Breast size and weight
Amount of fatty tissue
Depth of the subcutaneous fat layer
The nurse has asked a client if she has noticed any lumps or swelling in her breasts. The client responds “yes.” What would the nurse ask next?
“Does the lump change over the course of your menstrual cycle?”
“Has there been any corresponding change in your breast size?”
“Have any of the other women in your family had this happen?”
“What do you think is causing this change?”
When taking a health history for a client, which factor should the nurse identify as placing the client at increased risk for breast cancer?
The client smokes six to eight cigarettes per day
The client had her first child at age 38
The client breast-fed her child for a full year
The client has a low body mass index
What factor should a nurse include when discussing risk factors about breast cancer for a group of women?
Early menarche
Early menopause
Consumption of a high-protein diet
One or more pregnancies before age 20
While assessing a woman's breasts, the nurse notes a pronounced and asymmetric pattern of veins on the client's breasts. Follow-up care is ordered because the nurse should suspect which of the following?
Pregnancy
A low platelet count
Fibrocystic changes
Malignancy
A 42-year-old client says she does not perform breast self-examination because she believes that mammograms are more thorough. Which response by the nurse would be most appropriate?
“Once you hit age 50, you really won't have a choice about doing them.”
“Be sure to have your breasts checked by a doctor and have a mammogram every year.”
“Mammograms don't always detect the lumps that you might feel.”
“You should do the examination. It's the best way to detect breast cancer early.”
The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. What would the nurse expect to find?
Red and scaling on the areola
Orange-peel skin
Nipple retraction
Dark pink areola
A woman reports a sudden onset of spontaneous nipple discharge. What would the nurse do next?
Collect a sample for culture and sensitivity testing.
Refer the client for cytologic study of the discharge.
Observe the breast for eversion of the nipples.
Reassure the woman that this is a result of hormonal fluctuations.
While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings?
Pericardial friction rub
Aortic ejection click
Summation gallop
Midsystolic click
A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. How would the students identify this layer?
Epicardium
Endocardium
Myocardium
Pericardium
The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle?
Beginning of diastole
Isometric contraction
Closure of the semilunar valves
Closure of the atrioventricular valves
The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate?
Increased jugular venous pressure
Bradycardia
Decreased blood pressure
Dysrhythmias
The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?
The client may be at increased risk for myocardial infarction.
The client may have developed a cardiac conduction problem.
The client may be experiencing symptoms of heart failure.
The client's cardiac problem is being adequately compensated for.
The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse?
Perform the exam with the client in a supine position.
Inspect the suprasternal notch or around the clavicles.
Have the client look straight ahead with chin slightly lifted.
Have the client sit up at a 90-degree angle.
The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?
Second intercostal space, left sternal border
Third intercostal space, left axillary line
Fourth intercostal space, left sternal border
Fifth intercostal space, left midclavicular line
A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary
Caucasians usually possess greater lifestyle risks for CAD than African Americans.
Hypertension is seen more in white women than in African American women.
Hypertension is more prevalent in African Americans than among Caucasians.
Hispanic Americans have a higher rate of CAD than white Americans.
The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear?
Split
Diminished
Accentuated
Varying
After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which location as Erb point?
Third intercostal space at the left sternal border
Fifth intercostal space near the left midclavicular line
Second intercostal space at the right sternal border
Second or third intercostal space at the left sternal border
During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse?
Popliteal
Brachial
Temporal
Femoral
During a health visit, a client says, “I know that arteries and veins are both blood vessels, but what's the difference?” Which statement would the nurse include in the response?
“Arteries have thicker walls than veins.”
“Arteries have a lower pressure than veins.”
“Arteries carry 70% of the body's blood volume.”
“Arteries carry waste from the tissues.”
A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area?
Posterior neck
Axillary area
Inguinal area
Upper arm
An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. What would the nurse suspect?
Venous insufficiency
Arterial insufficiency
Musculoskeletal weakness
Diabetic neuropathy
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral?
Dependent edema
Stasis ulceration
Arterial occlusion
Venous insufficiency
When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency?
14-year history of smoking a pack a day
Intake of 1 to 2 alcoholic drinks per day
A family history of arterial insufficiency
Sedentary lifestyle
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?
Apply a tourniquet for 2 minutes and then reassess.
Use Doppler ultrasonography to locate the pulse.
Document “absence of dorsalis pedis pulse.
Auscultate the anatomic area with a stethoscope.
The nurse is assessing a client who has been referred to the clinic because of possible arterial insufficiency. What assessment finding should the nurse
Reddish-blue coloration of the shins and feet
Dry, shiny, hairless shins and feet
Numbness and tingling of the lower extremities
Pitting edema to the feet and ankles
