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Advanced Health Assessment Exam 2 Review Questions & Answers 2024-2025, Exams of Nursing

Advanced Health Assessment Exam 2 Review Questions & Answers 2024-2025/Advanced Health Assessment Exam 2 Review Questions & Answers 2024-2025/Advanced Health Assessment Exam 2 Review Questions & Answers 2024-2025

Typology: Exams

2024/2025

Available from 10/07/2024

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Download Advanced Health Assessment Exam 2 Review Questions & Answers 2024-2025 and more Exams Nursing in PDF only on Docsity!

Answers 2024-

Advanced Health Assessment Exam 2 Review Questions &

Answers 2024-

A palpable vibration increased with lobar pneumonia is also known as: A. Rhonchi B. Resonance C. Fremitus D. Crackles - C. Fremitus (key term is "palpable"

Your patient is exhibiting rapid shallow breathing, with a respiratory rate > respirations per minute. Which of the following conditions are they experiencing? A. hypoxemia B. tachypnea C. fremitus D. resonance - B. tachypnea

Increased tactile fremitus would be evident in an individual who has which of the following conditions? A. emphysema B. pneumonia C. crepitus D. pneumothorax - B. pneumonia

Fremitus is a palpable vibration. Increased fremitus occurs with compression or consolidation of lung tissue (ex. lobar pneumonia)

Which of the following terms is used to describe a decreased level of oxygen (O2) in the blood? A. anemia B. hypercapnia C. hypoxemia D. emphysema - C. hypoxemia

Answers 2024-

The nurse is assessing a patient who has emphysema. They note a course, crackling sensation that is palpable over the skin surface. This is known as: A. hypoxemia b. crackles C. fremitus D. crepitus - D. crepitus

Upon receiving the patient's lab results, the nurse notes the patient has an increased level of carbon dioxide in the blood. Which of the following conditions would the patient be experiencing? A. resonance B. hypercapnia C. fremitus D. tachypnea - B. hypercapnia

The nurse is auscultating a patient's lungs and hears discontinuous, high-pitched, short, popping sounds heard during inspiration, and not cleared by coughing. These are described as: A. bradypnea B. rhonchi C. crackles D. wheezing - C. crackles

The nurse is assessing a patient's lungs by using the percussion technique. Which sound would the nurse expect to hear over healthy lung tissue? A. resonance B. orthopnea C. crackles D. tachypnea - A. resonance

A clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is: A. periodic breathing patterns

Answers 2024-

B. pursed lip breathing C. unequal chest expansion D. hyperventilation - B. pursed lip breathing

An individual with COPD may purse the lips in a whistling position. By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse.

Which of the following are functions of the respiratory system? (Select all that apply) A. supplying oxygen to the body for energy production B. removing carbon dioxide as a waste product C. wound repair D. maintaining acid-base balance E. maintenance of heat exchange F. identification - A. supplying oxygen to the body for energy production B. removing carbon dioxide as a waste product D. maintaining acid-base balance E. maintenance of heat exchange

Stridor is a high pitched, inspiratory crowing sound commonly associated with: A. upper airway obstruction B. atelectasis C. congestive heart failure D. Pneumothorax - A. upper airway obstruction

Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.

Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position? A. upper lobes-lateral chest B. upper lobes-posterior chest

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C. lower lobes-posterior chest D. lower lobes - anterior chest - C. lower lobes - posterior chest

The posterior chest is almost all lower lobe

The function of the trachea and bronchi is to A. transport gases between the environment and the lung parenchyma B. Condense inspired air for better gas exchange C. Moisturize air for optimum respiration D. Increase air turbulence and velocity for maximum gas transport - A. transport gases between the environment and the lung parenchyma

Which of the following chest configurations is an exaggerated posterior curvature of the thoracic spine that is associated with aging and physical fitness? A. scoliosis B. barrel chest C. kyphosis D. pectus excavatum - C. Kypohosis

Causes significant back pain and limited mobility. It is associated with aging, and people with adequate exercise habits are less likely to have kyphosis. Scoliosis is S shaped curvature of the spine Barrel chest is equal AP to transverse diameter and is associated with aging and chronic emphysema or asthma. Pectus excavatum is a markedly sunken sternum and adjacent cartilages that is congenital.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ___________________ comparison. A. side-to-side B. top-to-bottom C. posterior-to-anterior D. interspace by interspace - A. side to side

Answers 2024-

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? A. wheezes B. bronchial sounds C. bronchophony D. crackles - A. wheezes

Wheezes occur when air is squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions or tumors.The

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? A. absent or decreased breath sounds B. productive cough with thin, frothy sputum C. chest pain that is worse on deep inspiration and dyspnea D. diffuse infiltrates with areas of dullness on percussion - C. chest pain that is worse on deep inspiration and dyspnea

Undissolved materials originating in the legs or pelvis detach and travel through the venous system, returning blood to the right side of the heart and lodge to occlude the pulmonary vessels.

The direction of blood flow through the heart is best described by which of these? A. Vena cava, right atrium, right ventricle, lungs, pulmonary artery, left atrium, left ventricle B. Right atrium, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, left ventricle C. Aorta, right atrium, right ventricle, lungs, pulmonary vein, left atrium, left ventricle, vena cava D. right atrium, right ventricle, pulmonary vein, lungs, pulmonary artery, left atrium, left ventricle - B. Right atrium, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, left ventricle

Answers 2024-

Returning blood from the body empties into the right atrium from the superior vena cava (SVC) and inferior vena cava (IVC), and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The luns oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. it goes from there to the left ventricle and then out of the body through the aorta.

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: A. mitral and tricuspid B. tricuspid and aortic C. aortic and pulmonic D. mitral and pulmonic - C. aortic and pulmonic

Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (MI) closes just before the tricuspid component (T1)

Which of these statements describes the closure of the valves in a normal cardiac cycle? A. the aortic valve closes slightly before the tricuspid valve. B. the pulmonic valve closes slightly before the aortic valve. C. the tricuspid valve closes slightly later than the mitral valve. D. Both the tricuspid and pulmonic valves close a the same time. - C. the tricuspid valve closes slightly later than the mitral valve.

The second heart sound (S2) occurs with closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base of the heart.

When you are assessing your patient's heart sounds, you notice a murmur. You listen with the bell and would describe the murmur as moderately loud and easy to hear. Which grade would you chart?

Answers 2024-

A. Grade i B. Grade V C. Grade iii D. Grade vi - C. Grade iii

Grade i - barely audible, heard only in a quiet room and then with difficulty. Grade ii - clearly audible, but faint Grade iii - moderately loud, easy to hear Grade iv - loud, associated with a thrill palpable on the chest wall Grade v - very loud, heard with one corner of the stethoscope lifted off the chest wall. Grade vi - loudest, still heart with entire stethoscope lifted just off the chest wall

a murmur is a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels.

How should the nurse document mild, slight pitting edema on the ankles of a heart failure patient? A. 1+ B. 2+ C. 3+ D. 4+ - A 1+

1+ = mild pitting 2+ = moderate pitting, indentation subsides rapidly 3+ = deep pitting, indentation remains for a short time, leg looks swollen. 4+ very deep pitting indentation lasts a long time, leg is grossly swollen and distorted.

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI? (Select all that apply) A. ethnicity B. abnormal lipids

Answers 2024-

C. smoking D. gender E. hypertension F. diabetes G. family history - B. abnormal lipids C. smoking E. hypertension F. diabetes

modifiable risk factors are factors that can be treated or controlled. Ethnicity, gender and family history are not factors that can be treated or controlled.

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs? A. roll toward the left side B. roll toward the right side C. trendelenburg position D. prone position - A. roll toward the left side

Some murmurs disappear or are enhanced by a change in position. S3, S4 and mitral systolic murmurs may be heard only when on the left side. diastolic murmurs may only be heard when the person is leaning forward in the sitting position.

Which statement is true regarding the arterial system? A. arteries are large-diameter vessels B. the arterial system is a high-pressure system C. the walls of arteries are thinner than those of the veins D. arteries can greatly expand to accommodate a large blood volume increase - B. the arterial system is a high-pressure system

The heart pumps freshly oxygenated blood through the arteries to the body tissues. The pumping heart makes this a high pressure system.

Answers 2024-

When assessing a patient the nurse is unable to palpate the left dorsalis pedis pulse. What should the nurse do first? A. document the finding B. use the doppler to assess the pulse C. call the physician and tell them the patient has no pulse. D. start assessing the next patient - B. use the doppler to assess the pulse

The first thing that you should do is find a doppler and see if the pulse can be heard through ultrasound

Pulse rating system: O = absent 1+ = weak 2+ = normal 3+ increased, full, bounding

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. intermittent claudication. B. sore muscles C. muscle cramps D. venous insufficiency - A. intermittent claudication

The pain is brought on by activity and relieved with rest.

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A. to measure the rate of lymphatic drainage. B. To evaluate the adequacy of capillary patency before venous blood draws. C. To evaluate the adequacy of collateral circulation before cannulating the radial artery

Answers 2024-

D. to evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded. - C. to evaluate the adequacy of collateral circulation before cannulating the radial artery

Modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would A. palpate the artery in the upper one third of the neck. B. listen with the bell of the stethoscope to assess for bruits C. palpate both arteries simultaneously to compare amplitude. D. instruct patient to take slow, deep breaths during auscultation. - B. listen with the bell of the stethoscope to assess for bruits.

If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery because this could create an artificial bruit and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck, excessive vagal stimulation here could slow down the heart rate, especially in older adults. Palpate only on e carotid artery at a time to avoid compromising arterial blood to the brain.

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 A. are often associated with venous disease B. occur in the presence of lymphadenopathy C. in the femoral arteries are caused by hypermetabolic states D. occur with turbulent flow, indicating partial occlusion - D. occur with turbulent flow, indicating partial occlusion

Answers 2024-

Bruits occur with turbulent blood flow, indicating partial occlusion. A bruit is audible when the artery is occluded by 1/2 to 2/3, it's loudness increases as atherosclerosis worsens and disappears when the lumen is completely occluded

You are caring for a 36 year old female patient admitted with c/o nausea and vomiting (N/V). What questions are appropriate to ask the patient to elicit health history information regarding her GI system? A. any changes in bowel habits? B. how long have you experienced this N/V? C None of the above. D. both a and b. - D. both A and B

These are examples of subjective data obtained to elicit GI history

True or false? A 24-hour recall of dietary intake is considered subjective data collected during a GI assessment. - True

You would want to know what the patient has eaten for the last 24 hours to determine if his or her symptoms have to do with what they have eaten in their daily diet.

You are caring for a 32 year old male patient with complaints of abdominal pain. After inspecting the patient's abdomen, you would be correct in performing what assessment technique next? A. deep palpation B. percussion C. light palpation D. auscultation - D. auscultation

You must perform the least invasive things first. if the person is having abdominal pain, deep palpation will most likely hurt and you will not be able to get through the whole examination if your perform this first.

Answers 2024-

You are watching another student perform auscultation of a patient's abdomen. Which statement by the other student demonstrates her understanding of the reason auscultation precedes percussion and palpation of the abdomen? A. "We need to determine areas of tenderness before using percussion and palpation." B. "It prevents distortion of bowel sounds that might occur after percussion and palpation." C. "It allows the patient more time to relax and therefore be more comfortable with the physical examination." D. "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation." - B. "It prevents distortion of bowel sounds that might occur after percussion and palpation."

Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

Which of the following observations should you make when inspecting a patient's abdomen? A. contour, symmetry and demeanor B. appearance of umbilicus C. skin and hair distribution D. all of the above - D. all of the above

during inspection you should observe contour (flat, rounded, concave, and distended), symmetry (any bulges or masses) appearance of umbilicus (midline, inverted, can be everted with pregnancy) skin (should be smooth and even, note any striae) pulsation or movement hair distribution (hair pattern) demeanor (comfortable, relaxed)

Answers 2024-

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. 1 minute B. 5 minutes C. 10 minutes D. 2 minutes in each quadrant - B. 5 minutes

Absent bowel sounds are rare. the nurse must listen for 5 minutes before deciding bowel sounds are completely absent. If unsure, ask for help from a more experienced nurse.

Methods to enhance abdominal wall relaxation during examination include: A. positioning the patient with the knees bent B. examining painful areas first. C. having the patient place arms above the head D. a cool environment - A. positioning the patient with the knees bent

Bending the knees promotes abdominal muscle relaxation. Painful areas should be examined last to avoid muscle guarding. Avoid having arms above the head; this increases abdominal wall tension. Keep the room warm to avoid chilling and tensing of muscles

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: A. increased salivation. B. increased liver size. C. increased esophageal emptying D. decreased gastric acid secretion - D. decreased gastric acid secretion

Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases.

Answers 2024-

The nurse is performing percussion during an abdominal assessment. She taps on the patient's left upper quadrant (spleen) and right upper quadrant (liver). The expected percussion note in these areas would be A. resonance B. dullness C. tympany D. hyperresonance - B. dullness

Percussion notes normally heard during he abdominal assessment may include tympany over the stomach and intestines, because air in the intestines rises to the surface when the person is supine and dullness over solid organs such as the liver and the spleen.

During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. The nurse recognizes this as A. abnormal: may be an umbilical hernia B. a normal result of aging C. caused by constipation D. a rare occurance - A. abnormal: may be an umbilical hernia

The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. the other responses are incorrect.

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: A. examine the tender area first. B. examine the tender area last. C. avoid palpating the tender area D. palpate the tender area first, and then auscultate for bowel sounds. - B. examine the tender area last.

Answers 2024-

The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

You are instructing a colleague who wants to know the best way to auscultate to bowel sounds. An appropriate response would be to start in the area where bowel sounds are prominent which is: A. the RLQ at the ileocecal valve B. the RUQ of the abdomen C. the LUQ of the abdomen D. the LLQ of the abdomen - A. the RLQ at the ileocecal valve

To effectively assess for bowel sounds start at the right lower quadrant. That is the location of the ieocecal valve and that is where the most active part of the bowel sounds will be. That's where our GI tracts are most active.

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: A. the largest quadrant of the breast. B. the location of most breast tumors C. where most of the suspensory ligaments attach. D. More prone to injury and calcifications than other locations in the breast. - B. the location of most breast tumors

Research on the incidence of breast cancer has revealed that cancerous breast tumors tend to appear in the upper outer quadrant (Tail of Spence) of either breast. However, a breast mass in any quadrant has the potential to be cancerous

A known risk factor for breast cancer includes: A. breastfeeding an infant for more than 6 months. B. a low cholesterol diet.

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C. physical activity D. Menstruation before age 12 or menopause after age 50. - D. Menstruation before age 12 or menopause after age 50

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: A. "don't worry about the pain; breast cancer is not painful." B. "I would like some more information about the pain in your left breast." C. "Oh, I had pain like that alter my son was born, it turned out to be a blocked milk duct." D. "Breast pain is almost always the result of benign breast disease." - B. "I would like some more information about the pain in your left breast."

Breast pain occurs with trauma, inflammation, infection, or benign breast disease The nurse will need to gather more information about the patient's pain rather than make statements that ignore the patient's concerns.

During an annual physical examination, a 43 year old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much easier job than I ever could to find a lump." The nurse should explain to her that: A. BSEs may detect lumps that appear between mammograms. B. BSEs are unnecessary until the age of 50 years C. She is correct -mammography is a good replacement for BSE. D. She does not need to perform BSEs as long as a physician checks her breasts annually. - A. BSEs may detect lumps that appear between mammograms.

The monthly practice of BSE, along with clinical breast examination and mammograms, are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experience examiner. However interval lumps may become palpable between mammograms.

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During the examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? A. breasts should always be symmetric. B. Assymetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. C. Assymetry is not unusual, but the nurse should verify that this change is not new. D. Assymetry of breast size and shape is very unusual and means she may have an inflammation or growth. - C. Assymetry is not unusual, but the nurse should verify that this change is not new.

The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size. Often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth.

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? A. normal nipple inversion is usually bilateral B. unilateral inversion of a nipple is always a serious sign C. whether the inversion is a recent change should be determined D. nipple inversion is not significant unless accompanied by an underlying palpable mass. - C. whether the inversion is a recent change should be determined

The nurse should distinguish between a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out, that is, if it is not fixed. Recent nipple retraction signifies acquired disease.

The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation by displaying the breast against the chest wall? A. supine with the arms raised over her head

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B. sitting with the arms relaxed at her sides C. supine with the arms relaxed at her sides D. sitting with the arms flexed and fingertips touching her shoulders - A. supine with the arms raised over her head

The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and medially displace it. Any significant lumps will then feel more distinct.

Which of these clinical situations would the nurse consider to be outside normal limits? A. a patient has had one pregnancy. Her breast examination reveals breasts that are soft and slightly sagging. B. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. C. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is somewhat engorged. She states that the examination is slightly painful. D. A patient has had two pregnancies. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples. - D. A patient has had two pregnancies. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, any discharge is abnormal. in nulliparous women, normal breast tissue feels firm, smooth, and elastic, after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm,

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transverse ridge of compressed tissue in the lower quadrants, known as the inframmamary ridge, is especially noticeable in large breasts.

The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? A. the best time to perform BSE is in the middle of the menstrual cycle. B. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue. C. the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. D. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born. - c. the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.

the nurse should help each woman establish a regular schedule of self care. The best time to conduct a BSE is right after the menstrual period, or the fourth through the seventh day of the menstrual cycle, when the breasts are the smallest and least congested.

The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is: A. on the same same every month B. daily, during the shower or bath. C. One week after her menstrual period. D. every year with her annual gynecologic examination - A. on the same day every month.

Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform BSEs on a monthly basis. the pregnant or menopausal woman who is not having menstrual periods should be advised to select a familiar date to examine her breasts each month. For example, her birth date or the day the rent is due. Choosing the same day of the month is a helpful reminder to perform the examination.

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A 54 year old man comes to the clinic with what he calls "a horrible problem". He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true? A. breast masses in men are difficult to detect because of minimal breast tissue. B. Breast cancer in men is unlikely to occur. C. One percent of all breast cancers occur in men. D. Gynecomastia is an enlarged firm nodule located in the breast tissue. - C. one percent of all breast cancers occur in men.

The early spreading to axillary lymph nodes is attributable to minimal breast tissue.

The nurse is palpating a female patient's breasts during a seated examination. She notes that the female has large pendulous breasts. What is the most appropriate course of action for the nurse to take? A. have a physician perform the assessment. B. have another nurse continue the assessment. C. use the bimanual technique D. refer the patient for a breast scan. - C. use the bimanual technique

For large pendulous breasts: With the client seated, the nurse would utilize the bimanual technique. Technique: palpate breast tissue against the supporting hand.

When examining a patient's cranial nerve (CN) function, the nurse remembers that the muscles in the neck that are innervated by CN XI( Spinal Accessory) are the:

A)sternomastoid and trapezius. B)spinal accessory and omohyoid. C)trapezius and sternomandibular. D)sternomandibular and spinal accessory. - Correct Answer is A The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

Answers 2024-2025

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____.

A) XI; palpating the anterior and posterior triangles B) XI; asking the patient to shrug her shoulders against resistance C) XII; percussing the sternomastoid and submandibular neck muscles D) XII; assessing for a positive Romberg sign - Correct Answer: B The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. To test CN XI, we would have the patient perform neck ROM against resistance and shrugging the shoulders against resistance.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?

A) Using gentle pressure, palpate with both hands to compare the two sides. B) Using strong pressure, palpate with both hands to compare the two sides. C) Gently pinch each node between one's thumb and forefinger and move down the neck muscle. D)Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern. - ANSWER: A Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, to compare the two sides symmetrically

The nurse is palpating the temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the tragus. Which of the following would be a normal finding? A) Nontender to palpation B) Crepitus C) The jaw locking D) Painful palpation - The correct answer is A

Answers 2024-2025

Nontender to palpation. When palpating the TMJ normal findings are smooth movement with no popping, crepitus, or tenderness.

Which of the following subjective data would you want to collect for your patient when performing a Head, A A. If they have unusually frequent or severe headaches B. If they have any dizziness C. If they have any neck pain D. If they have any chest pain E. If they have any history of neck injury or surgery - Correct answers are A, B, C, E.

Subjective data that you want to collect includes: Headache History of head injury, cosmetic or cranial surgery Dizziness Neck pain Noticed lumps or swelling History of neck injury or surgery

A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. A)Low gurgling; bell B) Loud, whooshing, blowing; diaphragm C) Soft, whooshing, pulsatile; bell D)High-pitched tinkling; diaphragm - Correct answer is C:

a bruit is a soft, whooshing, pulsatile sound that is best assessed with the bell of the stethescope.

Answers 2024-2025

The nurse is assessing the patient's trachea. Which of the following would be a normal finding? A. The trachea rising to midline when the patient swallows B. The trachea deviating to the left when the person swallows C. The trachea deviating to the right when the person swallows D. The trachea not moving when the person swallows - Correct answer is A.

The trachea should rise to the midline when the patient swallows. If it deviates to one side or the other that can indicate stroke or tumor.

The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check the extraocular eye muscles. The nurse knows that a healthy finding would be:

A. Each eye moves in opposite directions from each other B. There is parallel tracking of the object with both eyes. C. A rapid eye blink is expected. D. The light reflex of the eyes is located in the same position in each eye. - Correct Answer: B A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

When assessing the pupillary light reflex, the nurse should use which technique? A) Shine a penlight from directly in front of the patient and inspect for pupillary constriction. B) Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. C) Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. D) Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose. - Correct Answer: C

Answers 2024-2025

To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

A) consider this a normal finding. B) refer the individual for further evaluation. C) document this as an asymmetric light reflex. D) perform the confrontation test to validate the findings. - Correct Answer: A Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

The nurse is assessing the pupils of a patient with a pen light. Which finding would be considered normal? A)Both eyes cross when exposed to the light. B)The patient's pupils are fixed and dilated in response to light. C)Both pupils dilate in response to light. D)Both pupils constrict in response to light. - Correct Answer: D The pupils should constrict in response to light.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would:

A) suspect that there is an opacity in the lens or cornea. B) check the light source of the ophthalmoscope to verify that it is functioning. C) consider this a normal reflection of the ophthalmoscope light off the inner retina. D) continue with the ophthalmoscopic examination and refer the patient for further evaluation. - Correct Answer: C

Answers 2024-2025

The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

The nurse is charting on a patient's eye assessment and notes PERRLA. What does this stand for? A. Pupils Equal, Rigid, React to Light, and Accessible B. Pupils Even, Right, React to Light, and Accomodation C. Pupils Equal, Round, React to Light and Accomodation D. Pupils Even, Rigid, Restrict from Light, and Accomodation - The correct answer is C Pupils Equal, Round, React to Light, and Accommodation

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

A) decreased in the elderly. B) impaired in a patient with cataracts. C) stimulated by cranial nerves I and II. D) stimulated by cranial nerves III, IV, and VI. - Correct Answer: D Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI. Cranial nerve III (oculomotor) controls the inferior oblique, superior rectus and inferior rectus eye muscles Cranial nerve IV (Trochlear) control the superior oblique eye muscle Cranial nerve VI (Abducens) controls them lateral rectus muscle

The nurse is assessing her patient's pupillary response to light. She moves her penlight in from the side of the patient's face into the right eye. Both the right and left pupil constrict. How would these reflexes be described? A) Right eye consensual response, left eye direct response B) Right eye medial response, left eye lateral response C) Right eye dilation response, left eye constricting response