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Exam IV studyguide
Health Assessment
| Question | Answer |
|---|---|
| Before you begin auscultating heart sounds, inform the patient: | "I always listen to the heart in a number of places on the chest." |
| To assess the dorsalis pedis artery, you would palpate: | lateral to the extensor tendon of the great toe. |
| In performing auscultation of heart sounds, which sequence would you use? | Aortic area - pulmonic area - Erb's point - tricuspid area - mitral area |
| During an assessment, the nurse notes that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting edema. The right arm is normal. The patient had a mastectomy one year ago. The nurse suspects which problem: | lymphedema |
| Prior to drawing blood for an arterial blood gas (ABG), the lab tech will perform which assessment? | Modified Allen's test |
| While counting the apical pulse on a young adult patient, you notice an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be your response? | No further response is needed, as this is normal. |
| Select the best description of the mitral valve: | left atrioventricular valve. |
| During assessment, your patient tells you that her fingers often change color when she goes outside in cold. She details these episodes as her fingers first turning white, then blue, then red w/burning, throbbing pain. U suspect that she's experiencing? | Raynaud's syndrome. |
| A 35-year-old male is seen in the clinic for an "infected cut on my left thigh." Which of the following would you expect to find during your assessment of this patient? | Enlarged and tender inguinal nodes |
| During the examination of the lower extremities, you are unable to palpate the popliteal pulse. You should: | proceed with the exam. It is often impossible to palpate this pulse. |
| In cardiovascular assessment a "thrill" is: | a murmur that is palpable. |
| The tough, fibrous, double-walled sac that surrounds and protects the heart is: | pericardium |
| The examiner wishes to listen in the pulmonic valve area. To do this, the stethoscope would be placed at the: | second left intercostal space |
| Which of the following statements best describes the mechanism(s) by which venous blood returns to the heart? Question 14 answers | Intraluminal valves ensure unidirectional flow toward the heart. |
| Which of the following statements is true regarding the apical impulse? | Its location may be indicative of heart size. |
| The nurse wishes to listen in the aortic valve area. To do this, the stethoscope would be placed at the: | second right intercostal space |
| In your assessment of a 68-year-old male with recent onset of right-sided weakness, you hear a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This woud indicate: | blood flow turbulence. |
| Which of the following best describes what is meant by atrial kick: | the atria contract toward the end of diastole and push the remaining blood into the ventricles |
| The most common site for an aneurysm to form is: | the aorta |
| The muscular wall of the heart is called the: | myocardium |
| When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: | aortic, pulmonic |
| The electrical stimulus of the cardiac cycle follows which sequence: | SA node - AV node - bundle of His - bundle branches |
| The findings from your assessment of a 70-year-old male with pitting edema in both ankles include jugular vein distention when the head of the bed is elevated 45 degrees. This would indicate: | heart failure. |
| The component of the conduction system referred to as the pacemaker of the heart is the: | sinatrial (SA) node |
| The nurse would palpate around the medial malleolus to assess which pulse: | posterior tibial |
| The direction of blood flow through the heart is best described by which of the following? | Right atrium - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - left ventricle |
| A patient has been diagnosed with venous stasis. Which of the following would the nurse most likely observe: | a brownish discoloration to the skin of the lower leg |
| When listening to heart sounds, the nurse knows that which of the following statements concerning S1 is true: | S1 coincides w/carotid artery pulse |
| The precordium is: | the area on the anterior chest overlying the heart and great vessels |
| 67 yr old patient states that he recently began to develop cramp-like pain in calves when climbing 10 stairs to apartment. This pain is relieved by sitting for a few minutes; then he's able to resume activities. This patient is most likely experiencing: | claudication |
| In an adult, a sustained elevated heart rate of greater than 120 beats per minute can lead to: | decreased cardiac output. |
| A patient's capillary refill in the fingertips is found to be greater than 3 seconds. The student nurse understands this to mean: | cardiac output is decreased. |
| A patient has a positive Homan's sign. You know that a positive Homan's sign: | is indicative of possible deep vein thrombosis. |
| The RN is auscultating the heart sounds of a patient with severe chronic obstructive pulmonary disease (COPD). The heart sounds seem "far away." This should be documented as: | distant |
| The thin layer of tissue that lines the inner surface of the heart chambers and valves is called: | the endocardium |
| A 75-year-old male is here for "a routine physical." During the history the patient states he's been having difficulty in sleeping. "I have to get up several times a night to urinate." You should document this as: | Nocturia |
| A 70-year-old patient is scheduled for open-heart surgery. The physician plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: | "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation." |
| In assessing the carotid arteries of an older patient with cardiovascular disease, you would: | listen with the bell of the stethoscope to assess for bruits. |
| How would you document mild slight edema present at the ankles of a patient? | 1+/4+ |
| The nurse wishes to listen for a pericaridal friction rub. Select the best method of listening: | with the diaphragm, patient sitting up and leaning forward |
| The second heart sound (S2) is the result of: | closing of the aortic and pulmonic valves. |
| In your assessment of a normal adult, where would you expect to palpate the apical impulse? | Fifth left intercostal space at the midclavicular line |
| When performing a peripheral vascular assessment on a patient, you are unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. You would: | consider this a normal finding and proceed with the peripheral vascular evaluation. |
| When performing an assessment of a patient, you note the presence of an enlarged epitrochlear lymph node. You would carefully examine which of the following areas? | Examine the patient's lower arm and hand, checking for the presence of infection or lesions. |
| You note that a patient has a murmur and describe it as Grade III/VI. This signifies that the murmur is: | moderately loud, easy to hear. |
| Select the best description of the tricuspid valve: | right atrioventricular valve |
| The nurse is reviewing an assessment of a patient's peripheral pulses and notes that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse: | normal |
| Which of the following is a normal physiologic change associated with the aging process? | Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure |
| The nurse is performing a peripheral vascular assessment on a bedridden patient, & notes following findings in right leg: increased warmth, swelling, redness, tenderness to palpation, & positive Homan's sign. The nurse would: | seek emergency referral b/c of risk of pulmonary embolism. |
Created by:
chaptravelman
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