NURSING2058 Health Assessment Exam 2 Study Guide, Exams of Nursing

Download NURSING2058 Health Assessment Exam 2 Study Guide and more Exams Nursing in PDF only on Docsity! NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ Health Assessment Exam 2: Study Guide Chapter :  When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient’s body systems before proceeding with palpation. B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is significantly more than a “quick glance.” NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ a. Count the patient’s respirations. b. Bilaterally percuss the thorax, noting any differences in percussion tones. c. Call for a chest x-ray study, and wait for the results before beginning an assessment. d. Inspect the thorax for any new masses and bleeding associated with respirations. B Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patient’s physical status.  The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ a. Slope of the earpieces should point posteriorly (toward the occiput). b. Although the stethoscope does not magnify sound, it does block out extraneous room noise. c. Fit and quality of the stethoscope are not as important as its ability to magnify sound. d. Ideal tubing length should be 22 inches to dampen the distortion of sound. B The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner’s nose. Long tubing will distort sound. The fit and quality of the stethoscope are both important. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. b. Is used to listen for low-pitched sounds. c. Should be lightly held against the person’s skin to block out low- pitched sounds. d. Should be lightly held against the person’s skin to listen for extra heart sounds and murmurs. A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain.  The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Is often used to direct light onto the sinuses. b. Uses a short, broad speculum to help visualize the ear. c. Is used to examine the structures of the NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ internal ear. d. Directs light into the ear canal and onto the tympanic membrane. D The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares.  An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a. Using the large full circle of light when assessing pupils that are not dilated b. Rotating the lens selector dial to the black numbers to compensate for astigmatism NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus D The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.  The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ is “very anxious” about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and to take off his undergarments. d. Defer measuring vital signs until the end of the examination, which allows him time to become comfortable. A Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person’s vital signs, will gradually NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ accustom the person to the examination.  When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. Washing one’s hands after removing gloves is not necessary, as long as the gloves are still intact. b. Hands are washed before and after every NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ physical patient encounter. c. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. B The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when potential contact with any body fluids is present. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ c. “Your pulse is 80 beats per minute, which is within the normal range.” d. “I’m using my stethoscope to listen for any crackles, wheezes, or rubs.” C The sharing of some information builds rapport, as long as the patient is able to understand the terminology.  The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a. Examiner feel more comfortable and to gain control of the situation. b. Examiner to build rapport and to increase the patient’s confidence in him or her. 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Halfway through the examination B NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cry.  When preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the child’s clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during the examination. d. Initially focus the interactions on the child, essentially ignoring the parent until NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ the child’s trust has been obtained. C The best place to examine the toddler is on the parent’s lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.  The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate? a. Asking questions enhances the child’s autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ this age like to have choices d. Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available D Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?”  With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because a teen’s level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ D During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body image and often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.  When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes as possible. D When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished.  The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear gloves during any and all contact with patients. c. Wash hands before and after contact with each patient. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol- based hand rubs can be used if hands are not visibly soiled.  The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. b. A thorough history and physical assessment information should be obtained from the patient’s NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ family member. c. A complete history and physical assessment should be immediately performed to obtain baseline information. d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved. D Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessary in this situation. An assessment may be completed later after the distress is resolved.  When examining an infant, the nurse should examine which area first? a. Ear b. Nose NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ c. Throat d. Abdomen D The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last.  While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ C A 6-year-old child has a sense of modesty. The child should undress him or herself, leaving underpants on and using a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from the child’s head to the toes.  During auscultation of a patient’s heart sounds, the nurse hears an unfamiliar sound. The nurse should: NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ a. Document the findings in the patient’s record. b. Wait 10 minutes, and auscultate the sound again. c. Ask the patient how he or she is feeling. d. Ask another nurse to double check the finding. D If an abnormal finding is not familiar, then the nurse may ask another examiner to double check the finding. The other responses do not help identify the unfamiliar sound. MULTIPLE RESPONSE NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ 1. The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? Select all that apply. a. Warm the hands first before touching the patient. b. For deep palpation, use one long continuous palpation when assessing the liver. c. Start with light palpation to detect surface characteristics. d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps. e. Identify any tender areas, and palpate them last. f. Use the palms of the hands to assess temperature of the skin. A, C, D, E NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest. C The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.  When assessing a patient’s lungs, the nurse recalls that the left lung: NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach. A The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ lung because the heart bulges to the left. The posterior chest is almost all lower lobes.  Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL). B The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ adventitious sounds.  The primary muscles of respiration include the: a. Diaphragm and intercostals. b. Sternomastoids and scaleni. c. Trapezii and rectus abdominis. d. External obliques and pectoralis major. A The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles—sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles.  A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate? NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ a. Obtaining a detailed health history of the patient’s allergies and a history of asthma b. Telling the patient to sleep on his or her right side to facilitate ease of respirations c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week C The patient is experiencing paroxysmal nocturnal dyspnea—being awakened from sleep with shortness of breath and the need to be upright to achieve comfort. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Fifth intercostal space, midaxillary line (MAL) d. Over the lower lobes, posterior side A Normally, fremitus is most prominent between the scapulae and around the sternum. These sites are where the major bronchi are closest to the chest wall. Fremitus normally NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ a. Side-to-side b. Top-to-bottom c. Posterior-to-anterior d. Interspace-by-interspace A Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are not correct. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: a. Normally auscultated over the trachea. b. Bronchial breath sounds and normal in that location. c. Vesicular breath sounds and normal in that location. d. Bronchovesicular breath sounds and normal in that location. C Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where air flows through smaller bronchioles and alveoli. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the chest d. Lightly holding the bell of the stethoscope against the chest to avoid friction C Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ c. Decreased anteroposterior diameter. d. Bronchovesicular breath sounds throughout the lungs. B The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.  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 nurse’s next action should be to: a. Assure the mother that these signs are normal symptoms of a cold. b. Recognize that these are serious NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ signs, and contact the physician. c. Ask the mother if the infant has had trouble with feedings. d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure. 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 NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infant’s feeding is not a priority at this time.  When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? a. Crepitus palpated at the costochondral junctions b. No diaphragmatic excursion as a result of a child’s decreased inspiratory volume c. Presence of bronchovesicular breath sounds in the peripheral lung fields d. Irregular respiratory pattern and a respiratory rate of 40 breaths NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ d. Association with a pneumothorax. C Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.  During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort B Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ incisional pain.  During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Airway obstruction b. Emphysema c. Pulmonary consolidation d. Asthma C Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony (see Table 18-7).  The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are: a. Musical in quality. b. Usually caused by a pathologic NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ disease. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration. C Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area. B The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other responses are not useful for palpation.  Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation b. Inspection c. Percussion d. Auscultation NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ A Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.  The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed? a. Palpation of reportedly “tender” areas are avoided because palpation in these areas may cause pain. b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ breaths. d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched. D Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.  The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+  When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a. Consider this a normal finding. b. Palpate this area for an underlying mass. c. Reposition the hands, and attempt to NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment. A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.  The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ d. Decrease the amount of strength used when attempting to percuss over the abdomen. C The thickness of the person’s body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct.  A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? a. Unequal chest expansion b. Increased tactile fremitus c. Atrophied neck and trapezius muscles d. Anteroposterior-to-transverse NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ 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. (See Table 18-8 for descriptions of the other conditions.)  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, the 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: a. Asthma. b. Atelectasis. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ c. Lobar pneumonia. d. Heart failure. A Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma. (See Table 18-8 for descriptions of the other conditions.)  The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. b. Respiratory muscle strength increases to compensate for a decreased vital capacity. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ c. Decrease in small airway closure occurs, leading to problems with atelectasis. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil. D In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ complaints of a cough that is associated with rust-colored sputum, low- grade afternoon fevers, and night sweats for the past 2 months. The nurse’s preliminary analysis, based on this history, is that this patient may be suffering from: a. Bronchitis. b. Pneumonia. c. Tuberculosis. d. Pulmonary edema. C Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust- colored sputum in addition to other NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ symptoms of night sweats and low-grade afternoon fevers (see Table 18- 8).  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 patient? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds A NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia (see Table 18-8).  A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: a. Pneumonia. b. Postnasal drip or sinusitis. c. Exposure to irritants at work. d. Chronic bronchial irritation from smoking. B A cough that primarily occurs at night may indicate postnasal drip or NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ d. If the patient is modest, listening to sounds over his or her clothing or hospital gown A During auscultation of breath sounds with a stethoscope, listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.  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 NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ dullness upon percussion C Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes.  During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: a. Tactile fremitus. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ b. Crepitus. c. Friction rub. d. Adventitious sounds. B Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, such as after open thoracic injury or surgery.  The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: a. Atelectatic crackles that do not have a pathologic cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes. NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing B A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema. MULTIPLE RESPONSE NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ 1. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very soft voice. b. As the patient repeatedly says “ninety- nine,” the examiner clearly hears the words “ninety-nine.” c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long “ee-ee- ee” sound, the examiner also hears a long “ee- ee-ee” sound. e. As the patient says a long “ee-ee- NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+ ee” sound, the examiner hears a long “aaaaaa” sound. A, C, D As a patient repeatedly says “ninety-nine,” normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear “ninety-nine” is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony. When a patient says a long “ee-ee-ee” sound, normally the examiner also hears a long “ee-ee-ee” sound through auscultation, which is a measure of NURSING2058 Health Assessment Exam 2 study guide Q & As best exam solution guaranteed success 100% correct/verified answers latest update 2022/2023 RATED A+