CURRENT Medical
CURRENT Diagnosis
Medical and Treatment
Diagnosis 2025
and Treatment
Test Bank/Complete Guide
2019 Testbank/Studyguide
Chapter 2. Common Symptoms
1. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing throughnarrowed
bronchioles would produce which of these adventitious sounds?
a. Wheezes
b. Bronchial sounds
c. Bronchophony
d. Whispered pectoriloquy
ANS: A
Wheezes are caused by air squeezed or compressed through passageways narrowed almost to
closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic
emphysema.
2. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he
has 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 nurses nextaction should be to:
a. Assure the mother that these signs are normal symptoms of a cold.
b. Recognize that these are serious signs, and contact the physician.
c. Ask the mother if the infant has had trouble with feedings.
Perform a complete cardiac assessment because these signs are probably indicative of early heartfailure.
d.
ANS: B
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and
no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles
and nasal flaring indicate increased inspiratory effort, as in pneumonia, acuteairway obstruction, asthma,
and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate
heart failure, and an assessment of the infants feeding is not a priority at this time.
3. A teenage patient comes to the emergency department with complaints of an inability to breathe and
a sharp pain in the left side of his chest. The assessment findings include cyanosis,tachypnea, tracheal
deviation to the right, decreased tactile fremitus on the left, hyperresonanceon the left, and decreased
breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
a. Bronchitis.
b. Pneumothorax.
, c. Acute pneumonia.
d. Asthmatic attack.
ANS: B
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the
pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or
absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest
,expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the
presence of pneumothorax.
4. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. Thistest is
used to confirm a(n):
a. Inflamed liver.
b. Perforated spleen.
c. Perforated appendix.
d. Enlarged gallbladder.
ANS: C
An inflamed or perforated appendix irritates the iliopsoas muscle, producing pain in the RLQ.
5. Which statement indicates that the nurse understands the pain experienced by an older adult?
a. Older adults must learn to tolerate pain.
b. Pain is a normal process of aging and is to be expected.
c. Pain indicates a pathologic condition or an injury and is not a normal process of aging.
d. Older individuals perceive pain to a lesser degree than do younger individuals.
ANS: C
Pain indicates a pathologic condition or an injury and should never be considered something thatan older
adult should expect or tolerate. Pain is not a normal process of aging, and no evidence suggests that pain
perception is reduced with aging.
6. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in
appearance, and appear to have deep crypts. What is correct response to these findings?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
c. Continue with the assessment, looking for any other abnormal findings.
d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B
The tonsils are the same color as the surrounding mucous membrane, although they look moregranular and
their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.
7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother
states, I think she is getting her first tooth because she has started drooling a lot. The nurses best
response would be:
a. Youre right, drooling is usually a sign of the first tooth.
b. It would be unusual for a 3 month old to be getting her first tooth.
c. This could be the sign of a problem with the salivary glands.
d. She is just starting to salivate and hasnt learned to swallow the saliva.
, ANS: D
In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow
the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.
8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected forthis
patient?
a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal
hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva
production decreases.
9. The nurse is palpating the sinus areas. If the findings are normal, then the patient should reportwhich
sensation?
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation inpersons
with chronic allergies or an acute infection (sinusitis).
10. A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend
who just died from cancer of the prostate. He is concerned this will happen to him. Howshould the nurse
respond?
a. The swelling in your prostate is only temporary and will go away.
b. We will treat you with chemotherapy so we can control the cancer.
c. It would be very unusual for a man your age to have cancer of the prostate.
d. The enlargement of your prostate is caused by hormonal changes, and not cancer.
ANS: D The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1
in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by
hormonal imbalance that leads to the proliferation of benign adenomas.The other responses are not
appropriate.
11. A patient reports excruciating headache pain on one side of his head, especially around his eye,
forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The
nurse should suspect:
a. Hypertension.
CURRENT Diagnosis
Medical and Treatment
Diagnosis 2025
and Treatment
Test Bank/Complete Guide
2019 Testbank/Studyguide
Chapter 2. Common Symptoms
1. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing throughnarrowed
bronchioles would produce which of these adventitious sounds?
a. Wheezes
b. Bronchial sounds
c. Bronchophony
d. Whispered pectoriloquy
ANS: A
Wheezes are caused by air squeezed or compressed through passageways narrowed almost to
closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic
emphysema.
2. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he
has 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 nurses nextaction should be to:
a. Assure the mother that these signs are normal symptoms of a cold.
b. Recognize that these are serious signs, and contact the physician.
c. Ask the mother if the infant has had trouble with feedings.
Perform a complete cardiac assessment because these signs are probably indicative of early heartfailure.
d.
ANS: B
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and
no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles
and nasal flaring indicate increased inspiratory effort, as in pneumonia, acuteairway obstruction, asthma,
and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate
heart failure, and an assessment of the infants feeding is not a priority at this time.
3. A teenage patient comes to the emergency department with complaints of an inability to breathe and
a sharp pain in the left side of his chest. The assessment findings include cyanosis,tachypnea, tracheal
deviation to the right, decreased tactile fremitus on the left, hyperresonanceon the left, and decreased
breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
a. Bronchitis.
b. Pneumothorax.
, c. Acute pneumonia.
d. Asthmatic attack.
ANS: B
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the
pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or
absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest
,expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the
presence of pneumothorax.
4. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. Thistest is
used to confirm a(n):
a. Inflamed liver.
b. Perforated spleen.
c. Perforated appendix.
d. Enlarged gallbladder.
ANS: C
An inflamed or perforated appendix irritates the iliopsoas muscle, producing pain in the RLQ.
5. Which statement indicates that the nurse understands the pain experienced by an older adult?
a. Older adults must learn to tolerate pain.
b. Pain is a normal process of aging and is to be expected.
c. Pain indicates a pathologic condition or an injury and is not a normal process of aging.
d. Older individuals perceive pain to a lesser degree than do younger individuals.
ANS: C
Pain indicates a pathologic condition or an injury and should never be considered something thatan older
adult should expect or tolerate. Pain is not a normal process of aging, and no evidence suggests that pain
perception is reduced with aging.
6. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in
appearance, and appear to have deep crypts. What is correct response to these findings?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
c. Continue with the assessment, looking for any other abnormal findings.
d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B
The tonsils are the same color as the surrounding mucous membrane, although they look moregranular and
their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.
7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother
states, I think she is getting her first tooth because she has started drooling a lot. The nurses best
response would be:
a. Youre right, drooling is usually a sign of the first tooth.
b. It would be unusual for a 3 month old to be getting her first tooth.
c. This could be the sign of a problem with the salivary glands.
d. She is just starting to salivate and hasnt learned to swallow the saliva.
, ANS: D
In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow
the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.
8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected forthis
patient?
a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal
hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva
production decreases.
9. The nurse is palpating the sinus areas. If the findings are normal, then the patient should reportwhich
sensation?
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation inpersons
with chronic allergies or an acute infection (sinusitis).
10. A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend
who just died from cancer of the prostate. He is concerned this will happen to him. Howshould the nurse
respond?
a. The swelling in your prostate is only temporary and will go away.
b. We will treat you with chemotherapy so we can control the cancer.
c. It would be very unusual for a man your age to have cancer of the prostate.
d. The enlargement of your prostate is caused by hormonal changes, and not cancer.
ANS: D The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1
in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by
hormonal imbalance that leads to the proliferation of benign adenomas.The other responses are not
appropriate.
11. A patient reports excruciating headache pain on one side of his head, especially around his eye,
forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The
nurse should suspect:
a. Hypertension.
