During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
When part of the lung is obstructed or collapsed
During an 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?
This finding is not unusual, but the nurse should verify that this change is not new
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:
I would like some more information about the pain in your left breast.”
The nurse is reviewing the characteristics of breath sounds. Which statement about broncho-vesicular breath sounds is true? They are
expected near the major airways
The tissue that connects the tongue to the floor of the mouth is the:
frenulum
The primary muscles of respiration include the:
diaphragm and intercostals.
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
constriction of both pupils occurs in response to bright light.
A patient’s laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the _____ gland.
thyroid
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
refer the patient because of the suspicion of melanoma on the basis of her symptoms.
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?
Supine with arms raised over her head
The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person’s:
circulatory status.
The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct?
“BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations.”
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer?
65 year old whose mother had breast cancer
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? “Tactile fremitus:
is caused by sounds generated from the larynx.”
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of
muffled voice sounds and symmetrical tactile fremitus
The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?
Pull the pinna up and back before inserting the speculum.
A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he “can’t see well” from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:
shadow or diminished vision in one quadrant or one half of the visual field
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal:
dullness.
The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
not palpable
The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?
Woman whose nipples are in different planes (deviated)
During auscultation of the lungs of an adult patient, the nurse notices the presence of bron-chophony. The nurse should assess for signs of which condition?
Pulmonary consolidation
A dark skinned African American patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient’s skin?
Ashen, gray, or dull
The primary purpose of the ciliated mucous membrane in the nose is to:
filter out dust and bacteria
When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:
ear dysplasia.
During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?
Listen to at least one full respiration in each location.
In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?
Enlarged superficial cervical nodes
The nurse is examining a patient’s ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
The purpose of cerumen is to protect and lubricate the ear
When assessing a patient’s lungs, the nurse recalls that the left lung
consists of two lobes
A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply
- Partial thickness skin erosion with loss of epidermis or dermis.
- Open blister areas have a red-pink wound bed.
The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient’s thyroxine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
Tachycardia
The nurse is assessing a 3 year old for “drainage from the nose.” On assessment, it is found that there is a purulent drainage from the left nares that has a very foul odor and no drainage from the right nares. The child is afebrile with no other symptoms. What should the nurse do next?
Perform an otoscopic examination of the left nares.
A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from:
migraine headaches.
The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique?
The best time to perform BSE is 4 to 7 days after the first day of the menstrual period.
The salivary gland that is the largest and located in the cheek in front of the ear is the _____ gland.
parotid
The nurse is auscultating the chest in an adult. Which technique is correct?
Use the diaphragm of the stethoscope held firmly against the chest.
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
Between the scapula
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, 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:
asthma.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?
Use the Snellen chart positioned 20 feet away from the patient
A woman is in the family planning clinic seeking birth control information. She states that her breasts “change all month long” and that she is worried that this is unusual. What is the nurse’s best response?
Tell her that, because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common.
When assessing the pupillary light reflex, the nurse should use which technique?
Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.
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.
side-to-side
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give to her?
t is probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
increased density of lung tissue.
A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?
An anteroposterior-to-transverse diameter ratio of 1:1
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:
dehydration.
When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:
vesicular breath sounds and are normal in that location.
The nurse has palpated a lump in a female patient’s right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o’clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphade-nopathy. Which of these statements reveals the information that is missing from the documenta-tion? It is missing information about:
the size of the lump.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for about 3 days with his feet down and he wants the nurse to evaluate his feet. During the assess-ment, the nurse might expect to find:
distended veins.
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 situation?
Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema
The nurse is assessing a patient’s eyes for the accommodation response and would expect to see which normal finding?
Dilation of the pupils
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.
- Voice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very soft voice
- When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said.
- As the patient says a long “ee-ee-ee” sound, the examiner also hears a long “ee-ee-ee” sound.
In performing a voice test to assess hearing, which of these actions would the nurse do?
Whisper a set of random numbers and letters and ask the patient to repeat them.
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
Using gentle pressure, palpate with both hands to compare the two sides.
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be important for the nurse to determine?
Where did it first appear—on the nipple, the areola, or the surrounding skin?
A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:
the patient can read at 20 feet what a person with normal vision can read at 30 feet.
When inspecting the anterior chest of an adult, the nurse should include which assessment?
The shape and configuration of the chest wall
The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is:
the same day every month.
Which of the following statements is true regarding the internal structures of the breast? The breast is:
composed of fibrous, glandular, and adipose tissue.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
Dysphagia
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:
atelectatic crackles, and that they are not pathologic.
In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:
the location of most breast tumors.
A patient presents with excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts about 1/2 to 2 hours, occurring once or twice each day. The nurse should suspect:
cluster headaches.
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
pearly gray and slightly concave.
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.
ipsilateral axillary
The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?
The image formed on the retina is upside down and reversed from its actual ap-pearance in the outside world
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull’s eye pattern across his midriff and behind his knees. The nurse suspects:
Lyme disease.
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
“This is a fungal infection caused by all the antibiotics you’ve received.”
Which statement about the apices of the lungs is true? The apices of the lungs:
extend 3 to 4 cm above the inner third of the clavicles.
A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, “Am I normal? I don’t seem to need a bra yet, but I have some friends who do. What if I never get breasts?” The nurse’s best response would be:
“I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.”
During an annual physical exam, a 43-year-old patient states that she doesn’t perform monthly breast self-examinations (BSE). She tells the nurse that she believes that mammograms “do a much better job than I ever could to find a lump.” The nurse should explain to her that:
BSEs may detect lumps that appear between mammograms.
The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?
If the drum has ruptured, then there will be purulent drainage.
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?
Wheezes
The nurse is testing a patient’s visual accommodation, which refers to which action?
Pupillary constriction when looking at a near object
An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon exami-nation?
Dry mucous membranes and cracked lips
A 65-year-old patient remarks that she just can’t believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her?
After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?
It should be determined whether the inversion is a recent change.
Which statement indicates a correct understanding of the difference between percussion and palpation
Auscultating before the percussion and palpation of the abdomen ensures that the examiner is listening to undisturbed bowel sounds. In addition, if the patient is complaining of pain, leaving the palpation until last allows the examiner to gather other data before potentially causing the patient more discomfort.
Place the palmar aspect of the fingers on your dominant hand flat and together on your patient's abdomen. Using a light, gentle, dipping motion, palpate for abnormalities, such as muscle guarding, rigidity, or superficial masses. Palpate clockwise, lifting your fingers as you move from one location to another.
Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.
During the physical examination of a patient, the nurse listens to the heart sounds to detect variations from normal. Which physical examination technique is the nurse performing? The nurse performs auscultation. Auscultation involves listening to the sounds of the body to detect abnormalities.