NR 304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26 / NR304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26: LATEST,CHAMBERLAIN COLLEGE OF NURSING

NR 304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26 / NR304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26: LATEST,CHAMBERLAIN COLLEGE OF NURSINGNR 304 STUDY GUIDE EXAM 1 comlte solutions ch-5 to 26 Chapter 21 Jarvis: Physical Examination & Health Assessment, 7th Edition 1.Which statement is true regarding the arterial system? The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _ artery. The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with ___ the left leg. The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? Which vein(s) is(are) responsible for most of the venous return in the arm? A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, “What happens to my circulation when this vein is removed?” The nurse should reply: The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? 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? 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? The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? 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 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: A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed “a sore” on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing: During an assessment, the nurse uses the profile sign to detect: The nurse is performing an assessment on an adult. The adult’s vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? 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. Next, the nurse should: The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) ___ pulse. The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? 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: How should the nurse document mild, slight pitting edema the ankles of a pregnant patient? A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: When assessing a patient’s pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: During an assessment, the nurse has elevated a patient’s legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be: During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel “heavy in the calf” and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient? When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: During a routine office visit, a patient takes off his shoes and shows the nurse “this awful sore that won’t heal.” On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: 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 patient is recovering from several hours of orthopedic surgery. During an assessment of the patient’s lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. Chapter 20 Jarvis: Physical Examination & Health Assessment, 7th Edition 1.The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? Which structure is located in the left lower quadrant of the abdomen? A patient is having difficulty swallowing medications and food. The nurse would document that this patient has: The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? A patient’s abdomen is bulging and stretched in appearance. The nurse should describe this finding as: The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a __ profile. While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds: The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: During an abdominal assessment, the nurse would consider which of these findings as normal? The nurse is assessing the abdomen of a pregnant woman who is complaining of having “acid indigestion” all the time. The nurse knows that esophageal reflux during pregnancy can cause: The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of: A nurse notices that a patient has ascites, which indicates the presence of: The nurse knows that during an abdominal assessment, deep palpation is used to determine: The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by: The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? 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 patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? Just before going home, a new mother asks the nurse about the infant’s umbilical cord. Which of these statements is correct? Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem? During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to: During an assessment, the nurse notices that a patient’s umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: During a health history, the patient tells the nurse, “I have pain all the time in my stomach. It’s worse 2 hours after I eat, but it gets better if I eat again!” Based on these symptoms, the nurse suspects that the patient has which condition? 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. Chapter 19: The Heart Jarvis: Physical Examination & Health Assessment, 7th Edition 1.The sac that surrounds and protects the heart is called the: The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: Which of these statements describes the closure of the valves in a normal cardiac cycle? The component of the conduction system referred to as the pacemaker of the heart is the: The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true? A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? 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: In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history? 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? In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: 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: During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n): During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? The nurse is preparing to auscultate for heart sounds. Which technique is correct? While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse’s response? When listening to heart sounds, the nurse knows that the S1: During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do? Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child? While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings? During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patient’s history, the nurse knows that this extra heart sound is most likely a(n): The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? A 30-year-old woman with a history of mitral valve problems states that she has been “very tired.” She has started waking up at night and feels like her “heart is pounding.” During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with: During a cardiac assessment on a 38-year-old patient in the hospital for “chest pain,” the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? The nurse knows that normal splitting of the S2 is associated with: During a cardiovascular assessment, the nurse knows that a thrill is: