Health Assessment

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  1. Which of the following statements describes the cardiovascular system most accurately? The cardiovascular system
    A. is a double pump with pulmonary and systemic elements
    B. has a heart with six chambers and valves
    C. includes concepts of pre contractility, after-contractility, and load.
    D. functions with a conduction system that starts in the ventricles.
  2. In a healthy patient, the myocardial cells in the ventricle depolarize and contract during
    A. prediastole
    B. diastole
    C. systole
    D. postsystole
  3. When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is
    A. S1 > S2
    B. S1 = S2
    C. S2 > S1
    D. No S1 is heard
  4. The nurse assesses the neck vessels in the patient with heart failure to determine which of the following?
    A. the strength of the carotid pulse
    B. the presence of bruits
    C. the highest level of jugular venous pulsation
    D. the strength of the jugular veins
  5. The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority?
    A. auscultate heart sounds.
    B. Inspect the precordium.
    C. Percuss the left border.
    D. Obtain a blood pressure.
  6. A patient visits the clinic with the controllable factors of smoking, high-fat diet, overweight, decreased activity, and high blood pressure. What concept should the nurse use when performing patient teaching?
    A. Teach the patient the most serious information.
    B. Give the patient brochures to review upon the next visit.
    C. Discuss risk facts that the patient is interested in modifying.
    D. Describe the consequences of risk factors to motivate the patient.
  7. Which of the following clusters of symptoms are  common in women preceding an MI?
    A. Chest pain, nausea, diaphoresis
    B. Weight gain, edema, nocturia
    C. Dizziness, palpitations, low pulse
    D. Fatigue, diffi culty sleeping, dyspnea
  8. The nurse auscultates a medium loud whooshing sound that softens between S1 and S2. The nurse documents this fi nding as which of the following?
    A. Grade III decrescendo systolic murmur
    B. Grade IV crescendo systolic murmur
    C. Grade II crescendo diastolic murmur
    D. Grade I decrescendo diastolic murmur
  9. The nurse auscultates an extra sound on a patient 1 week following an MI. It is immediately after S3 and is heard best at the apex. Which of the following does the nurse suspect?
    A. S3 gallop
    B. S4 gallop
    C. Systolic ejection click
    D. Split S2
  10. A patient has dyspnea, edema, weight gain, and intake greater than output. These symptoms are consistent with which nursing diagnosis?
    A. Ineffective cardiac tissue perfusion
    B. Decreased cardiac output
    C. Impaired gas exchange
    D. Excess fluid volume
  11. Which of the following anterior neck structures is found in the depression between the trachea and the sternomastoid muscle?
    A) Internal jugular vein
    B) External jugular vein
    C) Trachea
    D) Carotid artery
  12. Across the lifespan, a nurse knows that the female heart
    A) Is normally smaller than the male heart
    B) Weighs more than a male heart
    C) Is normally larger than a male heart
    D) Normally beats slower than a male heart
  13. The area known as Erb's point is the third site for auscultation on the precordium. Where is it located?
    A) 4th left rib space
    B) 3rd right rib space
    C) 4th right rib space
    D) 3rd left rib space
  14. The sternal angle at the 2nd rib space is also known as what?
    A) Erb's point
    B) Manubrium
    C) The aortic area
    D) The PMI
  15. To increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness, what would the nurse teach a patient? (Mark all that apply.)
    A) The importance of physical activity
    B) To exercise vigorously 3 or more days a week
    C) To “cool down” after exercise so as not to strain muscles
    D) To exercise for 20 or more minutes
    E) To swim, which is the best exercise
  16. The nurse is caring for a patient who has an elevated cholesterol level. To reduce the mean total blood cholesterol and LDL cholesterol levels, what would be important to teach this patient?
    A) Eat high-protein, low-fat meals
    B) Eat low-fat, low-cholesterol meals
    C) Eat high-protein, low-carbohydrate meals
    D) Eat low-cholesterol, low-carbohydrate meals
  17. A patient comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?
    A) Shortness of breath
    B) Painful breathing
    C) Rapid breathing
    D) Inability to breathe
  18. A 62-year-old woman states that she has to get up during the night to urinate. How would the nurse further assess this patient's nocturia?
    A) Ask the patient how often she thinks she should be getting up at night
    B) Ask the patient “Are you tired in the morning because of this?”
    C) Ask the patient whether siblings or parents had this problem
    D) Ask the patient “Have you made any changes because of this?”
  19. An 87-year-old woman has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the NP want to have this patient assessed for by a cardiologist?
    A) Stenotic aortic valve
    B) Atherosclerotic pulmonic valve
    C) Atherosclerotic stenotic carotid arteries
    D) Congenital stenotic carotid arteries
  20. Nursing students are learning how to objectively assess venous pulses. How would the nursing instructor teach the students to optimally position the patient for this procedure? (Mark all that apply.)
    A) Use a bright light for better visualization
    B) Sit the patient up at a 90°angle
    C) Emphasize the shadows of the pulsations with lighting
    D) Place the head of the bed 30° to 45°
    E) Have the patient turn the head away from the side being examined
  21. A 79-year-old man has come to the clinic for a routine checkup. He reports general malaise and chronic fatigue, stating “I just can't get out and work in the garden anymore. I really miss it.” The patient has a history of cardiomegaly with a hypertrophied left ventricle. Where would the nurse expect to find the PMI?
    A) Between the 4th and the 5th ICS at the MCL
    B) Lateral and inferior to the 4th and 5th ICS and the MCL
    C) Lateral and superior to the 4th and 5th ICS and the MCL
    D) Lower left sternal border
  22. The nursing instructor is discussing assessment of the heart with students. A student states that he has a patient with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling?
    A) A thrill
    B) A thrust
    C) A heave
    D) A normal finding
  23. While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should know that this would be documented as what type of sound?
    A) Paradoxical sound
    B) Split sound
    C) Pericardial murmur
    D) Pericardial friction rub
  24. A patient presents at the cardiology clinic for a checkup 6 months after MI. The patient is known to have a bundle branch block that delays activation of the right ventricle. What would the nurse expect to hear when auscultating heart sounds?
    A) Arrhythmia
    B) Extra sound
    C) Wide splitting
    D) Delayed S1
  25. A patient has been admitted to the cardiac unit and test results are available. The nurse is writing a plan of care for this patient. On what would the nurse base interventions?
    A) Patterns of subjective and objective data
    B) Patterns of test results
    C) Areas for care planning
    D) Areas that the patient requests
  26. An emergency department nurse is assessing a 62-year-old rancher who arrives at the ED with chest pain. The patient states that the pain gets worse with movement. What further assessment should the nurse make?
    A) Auscultation at the 5th ICS
    B) Palpation at the PMI
    C) Assessment of the precordium
    D) Palpation of the costochondral junction
  27. The nurse performs an admission assessment on a 52-year-old woman admitted through the ED with a myocardial infarction. The nurse charts “Swooshing sound heard over right carotid artery.” How should this documentation be corrected?
    A) “Murmur heard over right carotid artery”
    B) “Split sound auscultated over right carotid artery”
    C) “Right carotid bruit auscultated”
    D) Does not need to be corrected
  28. An 83-year-old woman presents at the office of her primary care physician with fatigue, heart palpitations, and a “wet” cough. What might the nurse suspect in this patient?
    A) Heart failure
    B) Atrial fibrillation
    C) Atrial hypertrophy
    D) Ventricular arrhythmia
  29. What feature of a newborn shunts blood from the right atrium directly into the left atrium, bypassing the lungs?
    A) Foramen ovale
    B) Ductus arteriosus
    C) Placental insufficiency
    D) Injection fraction
  30. Identify the structures and functions of the heart.
  31. Identify the location of the heart and common auscultory areas on the precordium.
  32. Identify teaching opportunities for cardiovascular health promotion and risk reduction.
  33. Collect data about common cardiovascular symptoms: chest pain, dyspnea, orthopnea, cough, diaphoresis, fatigue, edema, and nocturia.
  34. Collect objective data about the carotid artery, jugular veins, and heart.
  35. Identify normal and abnormal findings from the inspection, palpation, and percussion of the precordium.
  36. Auscultate normal and abnormal heart sounds, including S1, S2, split sounds, extra sounds, murmurs, and rubs.
  37. Use subjective and objective data to analyze findings and plan interventions related to the cardiovascular system.
  38. Document and communicate data about the cardiovascular system using appropriate medical terminology.
  39. Individualize cardiovascular health assessment considering the condition, age, gender, and culture of the patient.
  40. Identify anatomical landmarks that guide assessment of the abdomen and documentation of findings.
  41. Explain the structure and functions of abdominal organs, muscles and vascular structures.
  42. Identify teaching opportunities for health promotion and risk prevention associated with organs found within the abdomen.
  43. Collect subjective data including history, review of systems, and symptoms that affect the GI system.
  44. Collect objective data on the inspection, auscultation, percussion and palpation of the organs within the abdominal cavity.
  45. Individualize the comprehensive health assessment by considering the condition, age, gender, and culture of the patient.
  46. Identify normal, variations of normal and abnormal findings of the inspection, auscultation, percussion, and palpation of the organs located within the abdominal cavity.
  47. Compare abnormal conditions that occur in the abdominal cavity.
  48. Use subjective and objective assessment data to analyze findings, identify diagnoses, and plan interventions.
  49. Document and communicate data using appropriate terminology.
  50. The linea alba is located where?
    A) Middle of the ventral abdominal wall
    B) Lower edge of the costal margin
    C) Anterior-superior iliac spine of the iliac bones
    D) Xiphoid process of the sternum
  51. The anatomy class is learning about the abdomen. The instructor would tell the class that the abdominal cavity is bordered on the back by
    A) The lower rib cage
    B) The vertebral column
    C) The kidneys
    D) The midaxillary lines
  52. A group of students is giving a presentation about the spleen. What is one of the functions of the spleen?
    A) Stores albumin
    B) Produces white blood cells
    C) Stores vitamin E
    D) Activates B and T lymphocytes
  53. What does Healthy People have as its focus areas for the GI tract? (Mark all that apply.)
    A) Constipation and diarrhea
    B) Colorectal cancer
    C) Food-borne illness
    D) Hepatitis
    E) Gastroenteritis
  54. When assessing a clinic patient, the nurse asks if the patient has ever had varicella. The nurse knows that varicella always precedes what?
    A) Impetigo
    B) Shingles
    C) Hepatitis
    D) Measles
  55. The nurse is admitting a new patient to the floor and asks if the patient has any dizziness. Why does the nurse do this?
    A) To assess for heart problems
    B) To assess for pancreatic problems
    C) To check for possible dehydration
    D) To check for an absorption problem
  56. A student is performing a physical assessment on a patient. While assessing the abdomen, the student percusses the spleen. What sound would be normal for the student to hear?
    A) Tympany
    B) Dullness
    C) Hollow sound
    D) Friction rub
  57. When palpating a patient's liver, the nurse feels a firm edge. What would this indicate to the nurse?
    A) Cirrhosis
    B) Liver failure
    C) Calcification of the liver
    D) Splenomegaly
  58. The nurse is getting a shift report. One of the patients is reported to have jaundice and splenomegaly. The patient is African American. What would you expect this patient's medical diagnosis to be?
    A) Liver disease
    B) Leukemia
    C) Sickle cell anemia
    D) Colon cancer
  59. While auscultating a patient's abdomen, the student notes abnormal bowel sounds. The nurse's preceptor asks the student to describe the sounds. The student describes them as high-pitched, rushing sounds. The preceptor, an experienced nurse, would know that these sounds indicate what?
    A) Diarrhea
    B) Adynamic ileus
    C) Intestinal fluid
    D) Partial intestinal obstruction
  60. The nurse is caring for a patient who is vomiting. When inspecting the vomitus, the nurse notes that it appears to contain coffee grounds. This would indicate what to the nurse?
    A) Digested blood
    B) Decreased peristalsis
    C) Active bleeding
    D) Undigested blood
  61. The nurse is assessing a patient and notes dullness to percussion in the lowest point of the abdomen. When rolling the patient to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by
    A) CHF and pyelonephritis
    B) Cirrhosis and nephrosis
    C) Metastatic neoplasms and CAD
    D) CHF and CAD
  62. An emergency department nurse is caring for a 17-year-old patient who has severe pain in the umbilical area. Documentation shows that the patient exhibits “Rovsing's sign.” What might this patient's medical diagnosis be?
    A) Gastroenteritis
    B) Liver disease
    C) Appendicitis
    D) Enlarged spleen
  63. What organ in the abdomen provides the blood vessels to the intestinal tract?
    A) Mesentery
    B) Aorta
    C) Peritoneum
    D) Spleen
  64. Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called?
    A) Epigastric
    B) Hypogastric
    C) Hypochondriac
    D) Inogastric
  65. When performing an abdominal assessment, what is the correct sequence?
    A. Inspection, palpation, percussion, auscultation
    B. Palpation, percussion, inspection, auscultation
    C. Inspection, auscultation, percussion, palpation
    D. Auscultation, inspection, palpation, percussion
  66. A patient reports a long history of changes in bowel pat-tern. Which is the BEST question to determine normal bowel habit?
    A. How often do you have a bowel movement? B. What was your bowel pattern before you noticed the change?
    C. Is there a family history of IBD?
    D. Have any of your parents or siblings had cancer of the colon?
  67. When palpating the abdomen, the nurse notices a mass in the LUQ, lateral to the MCL. Which organ is involved?
    A. Liver
    B. Spleen
    C. Sigmoid colon
    D. Left kidney
  68. What percussion sound is heard over most of the  abdomen?
    A. Resonance
    B. Hyperresonance
    C. Dullness
    D. Tympany
  69. A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will illicit kidney pain?
    A. Rosving's sign
    B. Psoas sign
    C. First percussion for CVA tenderness
  70. When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following?
    A. Right renal artery
    B. Right femoral artery
    C. Right iliac artery
    D. Abdominal aorta
  71. A patient with a history of cirrhosis tells the nurse that his or her abdomen seems to be getting larger and that he or she has gained 20 lb in the last 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain?
    A. Listen for a fluid wave.
    B. Percuss the abdomen with the patient in different positions.
    C. Palpate lightly and note the movement on the surface.
    D. Inspect the abdomen with the patient in different positions.
  72. A patient with protuberant abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?
    A. Murphy's sign
    B. Psoas sign
    C. Rosving's sign
    D. Obturator sign
  73. Which assessment technique would best confirm splenic enlargement?
    A. Deep palpation under the left costal margin
    B. Fist percussion of the spleen with the patient in a sitting position
    C. Deep palpation over the RUQ with the patient lying on the right side
    D. Percussion to estimate the size of the spleen and gentle palpation
  74. When documenting a finding in the region over the stomach and above the umbilicus, the nurse would identify the region as
    A. epigastric
    B. hypogastric
    C. RUQ
    D. LUQ
Card Set:
Health Assessment
2013-11-12 17:27:36
health assessment

abdomen, cardio,
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