NSU Health Assessment Exam 2 Questions With Complete
Solutions
A nurse documents the abdomen to be scaphoid in shape
meaning... Correct Answers sunken in
A nurse percusses between the 9th and 11th intercostal space
just behind the left midaxillary line to assess the... Correct
Answers spleen
A patient arrives with an increased respiratory rate. Upon
assessment, there is decreased chest expansion on the left side,
dullness to percussion and decrease breath sounds. This is
indicative... Correct Answers Atelectasis
A patient arrives with disorientation, dyspnea, hypotension and
tachycardia. Crackles and rhonchi are auscultated. This patient
should be treated emergently for... Correct Answers ARDS
A patient complains of chest pain which is worse on deep
inspiration. Upon assessment, the nurse finds the patient to be
diaphoretic and hypotensive. Auscultation reveals the presence
of crackles and wheezing. This patient should be emergently
treated for... Correct Answers Pulmonary embolism
A patient who recently traveled out of the country returns with a
productive cough and complaints of night sweats. The nurse
suspects tuberculosis. Which diagnostic exam is usually done to
confirm TB? Correct Answers Chest x-ray
,A stab wound victim arrives to the ER with injury to the left
hemithorax. To which side would the nurse expect the trachea to
be shifted? Correct Answers Right side
Ascites can occur with which conditions? Correct Answers
CHF, portal hypertension, cirrhosis, hepatitis, pancreatitis,
cancer
Atelectasis is the collapse/shrinkage of sections of alveoli which
can be caused by... Correct Answers Obstruction, compression,
decreased surfactant
Describe the fluid wave test. Correct Answers - place the ulnar
surface of the patient's hand on the midline of their abdomen
- place your hands on each flank
- tap one side at a time and feel for distinct tap on opposite hand
Describe the normal bowel sounds. Correct Answers high
pitched clicks and gurgles, 5 to 30 per minute
Describe the shifting dullness test. Correct Answers - place the
patient in the supine position
- begin percussing the abdomen on top and work your way down
the sides
- listen for a change from tympany to dullness as fluid will have
shifted down the sides
Discuss areas of normal sound variation from underlying viscera
in the anterior chest wall. Correct Answers Dullness on left
chest along cardiac borders
Dullness on right chest along upper border of liver
, Tympany on left chest in gastric spaces
Discuss some developmental changes which should be
considered when assessing the respiratory capacity of an aging
adult. Correct Answers - cartilage calcification = decreased
thorax mobility
- respiratory muscle weakening
- decreased lung elasticity
- histologic changes (alveolar destruction) = decreased surface
area for gas exchange
Discuss the 4 major functions of the respiratory system. Correct
Answers oxygen supply, CO2 removal, acid base balance, heat
exchange
Discuss the assessment order for the abdomen. Correct Answers
Inspect, auscultate, percuss, palpate
Discuss the characteristics that should be inspected on the
anterior thorax. Correct Answers shape/configuration, facial
expression, level of consciousness, skin color, quality/depth of
respiration, accessory muscle use
Discuss the characteristics that should be inspected on the
posterior thorax. Correct Answers shape/configuration, skin
color, AP diameter, breathing position, straight spinous process
Discuss the characteristics that should be palpated on the thorax,
anteriorly and posteriorly. Correct Answers symmetrical chest
expansion, gently palpate the entire chest wall, tactile fremitus
Solutions
A nurse documents the abdomen to be scaphoid in shape
meaning... Correct Answers sunken in
A nurse percusses between the 9th and 11th intercostal space
just behind the left midaxillary line to assess the... Correct
Answers spleen
A patient arrives with an increased respiratory rate. Upon
assessment, there is decreased chest expansion on the left side,
dullness to percussion and decrease breath sounds. This is
indicative... Correct Answers Atelectasis
A patient arrives with disorientation, dyspnea, hypotension and
tachycardia. Crackles and rhonchi are auscultated. This patient
should be treated emergently for... Correct Answers ARDS
A patient complains of chest pain which is worse on deep
inspiration. Upon assessment, the nurse finds the patient to be
diaphoretic and hypotensive. Auscultation reveals the presence
of crackles and wheezing. This patient should be emergently
treated for... Correct Answers Pulmonary embolism
A patient who recently traveled out of the country returns with a
productive cough and complaints of night sweats. The nurse
suspects tuberculosis. Which diagnostic exam is usually done to
confirm TB? Correct Answers Chest x-ray
,A stab wound victim arrives to the ER with injury to the left
hemithorax. To which side would the nurse expect the trachea to
be shifted? Correct Answers Right side
Ascites can occur with which conditions? Correct Answers
CHF, portal hypertension, cirrhosis, hepatitis, pancreatitis,
cancer
Atelectasis is the collapse/shrinkage of sections of alveoli which
can be caused by... Correct Answers Obstruction, compression,
decreased surfactant
Describe the fluid wave test. Correct Answers - place the ulnar
surface of the patient's hand on the midline of their abdomen
- place your hands on each flank
- tap one side at a time and feel for distinct tap on opposite hand
Describe the normal bowel sounds. Correct Answers high
pitched clicks and gurgles, 5 to 30 per minute
Describe the shifting dullness test. Correct Answers - place the
patient in the supine position
- begin percussing the abdomen on top and work your way down
the sides
- listen for a change from tympany to dullness as fluid will have
shifted down the sides
Discuss areas of normal sound variation from underlying viscera
in the anterior chest wall. Correct Answers Dullness on left
chest along cardiac borders
Dullness on right chest along upper border of liver
, Tympany on left chest in gastric spaces
Discuss some developmental changes which should be
considered when assessing the respiratory capacity of an aging
adult. Correct Answers - cartilage calcification = decreased
thorax mobility
- respiratory muscle weakening
- decreased lung elasticity
- histologic changes (alveolar destruction) = decreased surface
area for gas exchange
Discuss the 4 major functions of the respiratory system. Correct
Answers oxygen supply, CO2 removal, acid base balance, heat
exchange
Discuss the assessment order for the abdomen. Correct Answers
Inspect, auscultate, percuss, palpate
Discuss the characteristics that should be inspected on the
anterior thorax. Correct Answers shape/configuration, facial
expression, level of consciousness, skin color, quality/depth of
respiration, accessory muscle use
Discuss the characteristics that should be inspected on the
posterior thorax. Correct Answers shape/configuration, skin
color, AP diameter, breathing position, straight spinous process
Discuss the characteristics that should be palpated on the thorax,
anteriorly and posteriorly. Correct Answers symmetrical chest
expansion, gently palpate the entire chest wall, tactile fremitus
