NSG3313 Adult Health Exam 3 Review Questions With
Complete Solutions
A student nurse prepares to assess a client for postural blood
pressure changes. Which action indicates the student nurse
needs further education?
A. letting 30 seconds elapse after each position change before
measuring BP and HR
B. obtaining the supine measurements prior to the sitting and
standing measurements
C. taking the client's BP with the client sitting on the edge of the
bed, feet dangling
D. positioning the client supine for 10 minutes prior to taking
the initial BP and HR Correct Answer A. letting 30 seconds
elapse after each position change before measuring BP and HR
Rationale: The following steps are recommended when
assessing clients for postural hypotension: (1) Position the client
supine for 10 minutes before taking the initial BP and HR
measurements; (2) reposition the client to a sitting position with
legs in the dependent position, and wait 2 minutes to reassess
both BP and HR measurements; (3) if the client is symptom free
or has no significant decreases in systolic or diastolic BP, assist
the client into a standing position, obtain measurements
immediately and recheck in 2 minutes; (4) continue
measurements every 2 minutes for a total of 10 minutes to rule
out postural hypotension. Return the client to supine position if
postural hypotension is detected or if the client becomes
symptomatic. Document HR and BP measured in each position
(e.g., supine, sitting, and standing) and any signs or symptoms
that accompanied the postural changes.
,Age-related changes associated with the cardiac system include
A. increase in the number of SA node cells.
B. endocardial fibrosis.
C. myocardial thinning.
D. decreased size of the left atrium. Correct Answer C.
myocardial thinning.
Rationale: Age-related changes associated with the cardiac
system include: endocardial fibrosis, increased size of the left
atrium, a decreasing number of SA node cells, and myocardial
thickening.
During auscultation of the lungs, what would a nurse note when
assessing a client with left-sided heart failure?
A. laborious breathing
B. wheezes with wet lung sounds
C. high-pitched sounds
D. stridor Correct Answer B. wheezes with wet lung sounds
Rationale: If the left side of the heart fails to pump efficiently,
blood backs up into the pulmonary veins and lung tissue. For
abnormal and normal breath sounds, the nurse auscultates the
lungs. With left-sided congestive heart failure, auscultation
reveals a crackling sound, wheezes, and gurgles. Wet lung
sounds are accompanied by dyspnea and an effort to sit up to
breathe. With left-sided congestive heart failure, auscultation
does not reveal a high pitched sound.
, During the auscultation of a client's heart sounds, the nurse notes
an S4. The nurse recognizes that an S4 is associated with which
condition?
A. heart failure
B. turbulent blood flow
C. diseased heart valves
D. hypertensive heart disease Correct Answer D. hypertensive
heart disease
Rationale: Auscultation of the heart requires familiarization with
normal and abnormal heart sounds. An extra sound just before
S1 is an S4 heart sound or atrial gallop. An S4 sound often is
associated with hypertensive heart disease. A sound that follows
S1 and S2 is called an S3 heart sound or a ventricular gallop. An
S3 heart sound is often an indication of heart failure in an adult.
In addition to heart sounds, auscultation may reveal other
abnormal sounds, such as murmurs and clicks, caused by
turbulent blood flow through diseased heart valves.
During the auscultation of a client's heart sounds, the nurse notes
an S4. The nurse recognizes that an S4 is associated with which
condition?
A. heart failure
B. turbulent blood flow
C. hypertensive heart disease
D. diseased heart valves Correct Answer C. hypertensive heart
disease
Complete Solutions
A student nurse prepares to assess a client for postural blood
pressure changes. Which action indicates the student nurse
needs further education?
A. letting 30 seconds elapse after each position change before
measuring BP and HR
B. obtaining the supine measurements prior to the sitting and
standing measurements
C. taking the client's BP with the client sitting on the edge of the
bed, feet dangling
D. positioning the client supine for 10 minutes prior to taking
the initial BP and HR Correct Answer A. letting 30 seconds
elapse after each position change before measuring BP and HR
Rationale: The following steps are recommended when
assessing clients for postural hypotension: (1) Position the client
supine for 10 minutes before taking the initial BP and HR
measurements; (2) reposition the client to a sitting position with
legs in the dependent position, and wait 2 minutes to reassess
both BP and HR measurements; (3) if the client is symptom free
or has no significant decreases in systolic or diastolic BP, assist
the client into a standing position, obtain measurements
immediately and recheck in 2 minutes; (4) continue
measurements every 2 minutes for a total of 10 minutes to rule
out postural hypotension. Return the client to supine position if
postural hypotension is detected or if the client becomes
symptomatic. Document HR and BP measured in each position
(e.g., supine, sitting, and standing) and any signs or symptoms
that accompanied the postural changes.
,Age-related changes associated with the cardiac system include
A. increase in the number of SA node cells.
B. endocardial fibrosis.
C. myocardial thinning.
D. decreased size of the left atrium. Correct Answer C.
myocardial thinning.
Rationale: Age-related changes associated with the cardiac
system include: endocardial fibrosis, increased size of the left
atrium, a decreasing number of SA node cells, and myocardial
thickening.
During auscultation of the lungs, what would a nurse note when
assessing a client with left-sided heart failure?
A. laborious breathing
B. wheezes with wet lung sounds
C. high-pitched sounds
D. stridor Correct Answer B. wheezes with wet lung sounds
Rationale: If the left side of the heart fails to pump efficiently,
blood backs up into the pulmonary veins and lung tissue. For
abnormal and normal breath sounds, the nurse auscultates the
lungs. With left-sided congestive heart failure, auscultation
reveals a crackling sound, wheezes, and gurgles. Wet lung
sounds are accompanied by dyspnea and an effort to sit up to
breathe. With left-sided congestive heart failure, auscultation
does not reveal a high pitched sound.
, During the auscultation of a client's heart sounds, the nurse notes
an S4. The nurse recognizes that an S4 is associated with which
condition?
A. heart failure
B. turbulent blood flow
C. diseased heart valves
D. hypertensive heart disease Correct Answer D. hypertensive
heart disease
Rationale: Auscultation of the heart requires familiarization with
normal and abnormal heart sounds. An extra sound just before
S1 is an S4 heart sound or atrial gallop. An S4 sound often is
associated with hypertensive heart disease. A sound that follows
S1 and S2 is called an S3 heart sound or a ventricular gallop. An
S3 heart sound is often an indication of heart failure in an adult.
In addition to heart sounds, auscultation may reveal other
abnormal sounds, such as murmurs and clicks, caused by
turbulent blood flow through diseased heart valves.
During the auscultation of a client's heart sounds, the nurse notes
an S4. The nurse recognizes that an S4 is associated with which
condition?
A. heart failure
B. turbulent blood flow
C. hypertensive heart disease
D. diseased heart valves Correct Answer C. hypertensive heart
disease
