NR 509 WEEK 5 QUIZ / NR509 WEEK 5 QUIZ: LATEST,CHAMBERLAIN COLLEGE OF NURSING

NR 509 WEEK 5 QUIZ / NR509 WEEK 5 QUIZ: LATEST,CHAMBERLAIN COLLEGE OF NURSINGNR 509 WEEK 5 QUIZ Question 1. Question : The primary muscles of respiration include the Student Answer: diaphragm and intercostals. sternomastoids and scaleni. trapezius and rectus abdominis. external obliques and pectoralis major. Question 2. Question : The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? Student Answer: Wheezes Bronchial sounds Bronchophony Whispered pectoriloquy Question 3. Question : A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? Student Answer: Absent or decreased breath sounds Productive cough with thin, frothy sputum Chest pain that is worse on deep inspiration, dyspnea Diffuse infiltrates with areas of dullness upon percussion Question 4. Question : When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is Student Answer: seen in patients with kyphosis. indicative of pectus excavatum. a normal finding in a healthy adult. an expected finding in a patient with a barrel chest. Question 5. Question : An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with Student Answer: asthma. atelectasis. lobar pneumonia. heart failure. Question 6. Question : The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? “Tactile fremitus Student Answer: is caused by moisture in the alveoli.” indicates that there is air in the subcutaneous tissues.” is caused by sounds generated from the larynx.” reflects the blood flow through the pulmonary arteries.” Question 7. Question : A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? Student Answer: Stridor Friction rub Crackles Wheezing Question 8. Question : A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had “a runny nose for a week.” When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse’s next action should be to Student Answer: assure the mother that these are normal symptoms of a cold. recognize that these are serious signs and contact the physician. ask the mother if the infant has had trouble with feedings. perform a complete cardiac assessment because these are probably signs of early heart failure. Question 9. Question : A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation? Student Answer: Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema Rasping cough, thick mucoid sputum, wheezing, bronchitis Productive cough, dyspnea, weight loss, anorexia, tuberculosis Fever, dry nonproductive cough, diminished breath sounds Question 10. Question : In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would Student Answer: palpate the artery in the upper one third of the neck. listen with the bell of the stethoscope to assess for bruits. palpate both arteries simultaneously to compare amplitude. instruct patient to take slow deep breaths during auscultation. Question 11. Question : 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 Student Answer: a valvular disorder. blood flow turbulence. fluid volume overload. ventricular hypertrophy. Question 12. Question : The direction of blood flow through the heart is best described by which of these? Student Answer: Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle Question 13. Question : The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. 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 Student Answer: increased cardiac output. another myocardial infarction. inflammation of the precordium. ventricular hypertrophy resulting from muscle damage. Question 14. Question : During a cardiovascular assessment, the nurse knows that a “thrill” is Student Answer: a vibration that is palpable. palpated in the right epigastric area. associated with ventricular hypertrophy. a murmur auscultated at the third intercostal space. Question 15. Question : The nurse is preparing to auscultate for heart sounds. Which technique is correct? Student Answer: Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Listen to the sounds only at the site where the apical pulse is felt to be the strongest. Listen for all possible sounds at a time at each specified area. Question 16. Question : In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? Student Answer: Increase in resting heart rate Increase in systolic blood pressure Decrease in diastolic blood pressure Increase in diastolic blood pressure Question 17. Question : A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, 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? Student Answer: This is the result of peripheral vasodilatation and is an expected change. Because of increased cardiac output, the blood pressure should be higher this time. This is not an expected finding because it would mean a decreased cardiac output. This would mean a decrease in circulating blood volume, which is dangerous for the fetus. Question 18. Question : 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 Student Answer: varicosities. a venous stasis ulcer. an arterial ischemic ulcer. deep vein thrombophlebitis. Question 19. Question : 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. Student Answer: normal absent bounding weak, thready Question 20. Question : 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? Student Answer: Ask the patient about a past history of frostbite. Suspect that the patient has a venous insufficiency problem. Consider this a delayed capillary refill time and investigate further. Consider this a normal capillary refill time that requires no further assessment. Question 21. Question : The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? Student Answer: Woman in her second month of pregnancy Person who has been on bed rest for 4 days Person with a 30-year, 1-pack-per-day smoking history Elderly person taking anticoagulant medication Question 22. Question : When auscultating over a patient’s femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that Student Answer: bruits are often associated with venous disease. bruits occur in the presence of lymphadenopathy. hypermetabolic states will cause bruits in the femoral arteries. bruits occur with turbulent blood flow, indicating partial occlusion. Question 23. Question : A patient has a positive Homans’ sign. The nurse knows that a positive Homans’ sign may indicate Student Answer: venous insufficiency. deep vein thrombosis. severe edema. problems with arterial circulation. Question 24. Question : The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? Student Answer: Normal ABI indices are from 0.50 to 1.0. The normal ankle pressure is slightly lower than the brachial pressure. The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. Question 25. Question : 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 the veins are removed?” The nurse should reply Student Answer: “Venous insufficiency is a common problem after this type of surgery.” “Oh, we have lots of veins—you won’t even notice that it has been removed.” “You will probably experience decreased circulation after the veins are removed.” “Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation.”