November 25, 2022

When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen, and says you’re tickling him. Which of the following would be most appropriate for the nurse to do?

Question 1When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen, and says you’re tickling him. Which of the following would be most appropriate for the nurse to do?

Ask the parent to discipline the child.

Explain the purpose of the exam to the child.

Palpate with the child’s hand under the nurse’s hand.

Omit the entire abdominal exam.

Question 2During a well-child visit, a parent asks the nurse how many hours a 4-year-old preschooler should sleep? Which answer by the nurse is correct? “Preschoolers typically sleep ….”

11- 13 hours per 24 hours.

6 – 8 hours per 24 hours.

9 – 10 hours per 24 hours.

16 hours per 24 hours.

Question 3After inspecting an adolescent male’s genitalia, the nurse documents the findings as Tanner stage 1. Which of the following findings would be most likely?

Genitalia are prepubertal and there is no pubic hair.

Adult configuration of penis, abundant, dark, curly, pubic hair.

Scrotum is dark, penis increased in size, pubic hair curly and dark.

Scrotum and testes slightly enlarged; sparse, long, downy pubic hair

Question 4While auscultating a client’s lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first?

Refer the client for further medical evaluation.

Auscultate for egophony.

Perform bronchophony

Have the client cough, then listen again.

Question 5A patient feels that drinking alcohol is beneficial to his heart. He may well tolerate up to two drinks per day but more than that amount has been linked to which disorder?

Acute rheumatic fever

Congenital hypercholesterolemia

Hypertension

Hypotension

Question 6Regarding assessment differences between different cultures/ethnicities, which of the following groups has lower mean resting pulse rates?

Hispanic males

Black males

Hispanic females

White males

Assessment of a client’s radial pulse reveals that it is normal and obliterates with moderate pressure. The nurse documents the pulse amplitude as which of the following?

Question 9 On auscultation of valvular sounds over the precordium, what area is auscultated at the third to fifth intercostal space at the left sternal border?

Mitral

Aortic

Tricuspid

Pulmonic

Erb’s Point

Question 10On auscultation of valvular sounds over the precordium, what area is auscultated at the second or third intercostal space at the left sternal border?

Tricuspid

Aortic

Pulmonic

Mitral

Erb’s Point

Question 11In many situations nurses elect to take blood pressure in the legs (ankle) , often because the arms have IVs or other lines. How does the ankle blood pressure value compare with the brachial blood pressure?

It will be lower since the ankles are further from the heart.

The blood pressure measurement is systemic and will always be the same over the entire body.

The ankle pressure will be higher since it is further from the heart and pressure has to be higher to reach the feet. In patients with peripheral vascular disease it will be even higher.

The ankle pressure in a healthy person is the same or slightly higher than the brachial blood pressure; if the patient has arterial insufficiency, the ankle pressure will be lower.

Question 12What would the nurse document when listening to breath sounds and hearing a low, soft sound with short expiration and long inspiration?

Vesicular breath sounds

Bronchovesicular breath sounds

Bronchial breath sounds

Adventitious breath sounds

Question 13The nurse is assessing the various lobes of the client’s lungs. To gather accurate data, the nurse must assess which lobe anteriorly, since this lobe does not extend to the posterior chest?

Left middle lobe

Right lower lobe

Right middle lobe

Left upper lobe

Question 14When auscultating the left carotid artery, the nurse notes a swishing sound. What would this suggest?

A narrowed vessel

Right ventricular failure

Increased central venous pressure

Decreased cardiac output

Question 15What would the nurse suspect when a cardiac client complains of not sleeping well and having to get up frequently at night to urinate?

Increased urination at rest may indicate heart failure.

The client has decreased performance levels of activities of daily living.

The client most likely sleeps without a pillow at night.

This indicates the heart is working efficiently.

Question 16The nurse is listening to the precordium, and identifies a heart murmur so loud it can be heard with the stethoscope not in full contact with the chest. What rating would this murmur merit?

Grade 5/6

Grade 1/6

Grade 2/6

Grade 4/6

Question 17A client is noted to be leaning forward with arms supporting body weight as the nurse enters the exam room. For what disease process should the nurse assess fully?

Chronic obstructive pulmonary disease

Congestive heart failure

Diabetes mellitus

System lupus erythematosus

Question 18Kyphosis is common in older adult resulting from loss of lung resiliency and loss of skeletal muscle

True

False

Question 19The provider notes that a patient is able to breathe only when propped up by two pillows. The term for this is :

Orthopnea

hemoptysis

Shortness of breath

emphysema

Question 20The nurse is analyzing the data from the assessment of a client’s heart and neck vessels. The client’s second heart sound (S2) corresponds with what event in the cardiac cycle?

Closure of the semilunar valves

Closure of the atrioventricular valves

Beginning of Systole

Diastolic filling

Question 1 When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen, and says you’re tickling him. Which of the following would be most appropriate for the nurse to do?

Question 2 During a well-child visit, a parent asks the nurse how many hours a 4-year-old preschooler should sleep? Which answer by the nurse is correct? “Preschoolers typically sleep ….”

Question 3 After inspecting an adolescent male’s genitalia, the nurse documents the findings as Tanner stage 1. Which of the following findings would be most likely?

Question 4 While auscultating a client’s lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first?

Question 5 A patient feels that drinking alcohol is beneficial to his heart. He may well tolerate up to two drinks per day but more than that amount has been linked to which disorder?

Question 6 Regarding assessment differences between different cultures/ethnicities, which of the following groups has lower mean resting pulse rates?

Question 7 A nurse assesses a client’s capillary refill and finds it to be about 4 seconds. Which of the following should the nurse do next?

Question 8 Assessment of a client’s radial pulse reveals that it is normal and obliterates with moderate pressure. The nurse documents the pulse amplitude as which of the following?

Question 9 On auscultation of valvular sounds over the precordium, what area is auscultated at the third to fifth intercostal space at the left sternal border?

Question 10 On auscultation of valvular sounds over the precordium, what area is auscultated at the second or third intercostal space at the left sternal border?

Question 11 In many situations nurses elect to take blood pressure in the legs (ankle) , often because the arms have IVs or other lines. How does the ankle blood pressure value compare with the brachial blood pressure?

Question 12 What would the nurse document when listening to breath sounds and hearing a low, soft sound with short expiration and long inspiration?

Question 13 The nurse is assessing the various lobes of the client’s lungs. To gather accurate data, the nurse must assess which lobe anteriorly, since this lobe does not extend to the posterior chest?

Question 14 When auscultating the left carotid artery, the nurse notes a swishing sound. What would this suggest?

Question 15 What would the nurse suspect when a cardiac client complains of not sleeping well and having to get up frequently at night to urinate?

Question 16 The nurse is listening to the precordium, and identifies a heart murmur so loud it can be heard with the stethoscope not in full contact with the chest. What rating would this murmur merit?

Question 17 A client is noted to be leaning forward with arms supporting body weight as the nurse enters the exam room. For what disease process should the nurse assess fully?

Question 18 Kyphosis is common in older adult resulting from loss of lung resiliency and loss of skeletal muscle

Question 19 The provider notes that a patient is able to breathe only when propped up by two pillows. The term for this is :

Question 20 The nurse is analyzing the data from the assessment of a client’s heart and neck vessels. The client’s second heart sound (S2) corresponds with what event in the cardiac cycle?

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When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen, and says you’re tickling him. Which of the following would be most appropriate for the nurse to do?

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