Unit 3 exam Health Assessment

1:
A nurse is inspecting a patient with chronic obstructive pulmonary disease (COPD). Which chest configuration should the nurse expect?
A. Barrel chest
B. Pectus excavatum
C. Pectus carinatum
D. Kyphosis

A. Barrel chest is commonly seen in patients with COPD due to chronic lung overinflation.

2:
When auscultating a patient's lungs, the nurse hears high-pitched, musical sounds on expiration. This finding is most indicative of:
A. Crackles
B. Rhonchi
C. Wheezes
D. Pleural friction rub

C. Wheezes are high-pitched, musical sounds caused by narrowing of the airways, commonly seen in asthma or COPD.

3:
A nurse is assessing a patient's lung sounds and notes crackles in the bases bilaterally. This finding is most commonly associated with:
A. Pneumothorax
B. Pulmonary edema
C. Emphysema
D. Bronchitis

B. Crackles in the lung bases are associated with fluid in the alveoli, often due to pulmonary edema.

4:
During a respiratory assessment, a patient is asked to say "99." The nurse hears the words clearly over the lung fields. This finding is known as:
A. Bronchophony
B. Egophony
C. Whispered pectoriloquy
D. Fremitus

A. Bronchophony is the abnormal transmission of sound where the spoken words are heard clearly, indicating lung consolidation.

5:
Which assessment finding is most consistent with pleural effusion?
A. Increased fremitus
B. Hyperresonance on percussion
C. Dullness to percussion
D. Wheezing

C. Dullness to percussion is a key finding in pleural effusion due to the presence of fluid in the pleural space.
Chapter 21: Assessing Heart and Neck Vessels

6:
Which of the following heart sounds is caused by the closure of the aortic and pulmonic valves?
A. S1
B. S2
C. S3
D. S4

B. S2 is produced by the closure of the aortic and pulmonic valves at the end of systole.

7:
A nurse assesses a client for jugular vein distention (JVD). Which client position is most appropriate for this assessment?
A. Sitting upright
B. Supine with the head of the bed elevated 30-45 degrees
C. Prone
D. Left lateral decubitus

B. JVD is best assessed with the client in a semi-Fowler's position, with the head elevated 30-45 degrees.

8:
The nurse auscultates a client's heart and hears a blowing, swooshing sound during systole. This sound is indicative of:
A. Heart murmur
B. Pericardial friction rub
C. Aortic stenosis
D. S3 heart sound

A. A heart murmur is a blowing or swooshing sound heard during systole or diastole, caused by turbulent blood flow.

9:
A patient presents with an irregularly irregular pulse, and the nurse suspects atrial fibrillation. What is the most important assessment for this client?
A. Listening for S3 heart sound
B. Auscultating for a murmur
C. Checking for peripheral edema
D. Assessing for signs of decreased perfusion

D. Atrial fibrillation may decrease cardiac output and perfusion, so assessing for signs of decreased perfusion (e.g., cyanosis, cold extremities) is crucial.

10:
Which of the following is an expected finding when palpating the carotid arteries of a healthy older adult?
A. Bounding pulse
B. Thready pulse
C. Equal bilateral pulses
D. Unequal pulses

C. The carotid arteries should have equal bilateral pulses in a healthy adult.
Chapter 22: Assessing Peripheral Vascular System

11:
A client presents with varicose veins. Which of the following symptoms is the client most likely to report?
A. Leg pain relieved with rest and elevation
B. Leg swelling that worsens with activity
C. Cool, cyanotic legs
D. Painful ulcers on the toes

A. Varicose veins cause discomfort that is relieved with rest and elevation of the legs.

12:
Which pulse site is located on the top of the foot between the first and second toes?
A. Femoral pulse
B. Popliteal pulse
C. Dorsalis pedis pulse
D. Posterior tibial pulse

C. The dorsalis pedis pulse is located on the top of the foot between the first and second toes.

13:
A nurse assesses a client for deep vein thrombosis (DVT). Which finding would most suggest the presence of a DVT?
A. Brown discoloration of the skin
B. Swelling and tenderness in one leg
C. Coolness and pallor of the affected leg
D. Visible dilated veins

B. Swelling and tenderness in one leg are classic signs of a DVT.

14:
Which of the following is the most reliable method for assessing peripheral edema?
A. Measuring ankle circumference
B. Checking skin turgor
C. Palpating for pitting edema
D. Comparing pedal pulses bilaterally

C. Palpating for pitting edema is a reliable method to assess the presence and severity of peripheral edema.