Nursing The Person With Althered Physical Health Bn805

64 Questions | Total Attempts: 42

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Nursing The Person With Althered Physical Health Bn805

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Questions and Answers
  • 1. 
    Pulse oximetry measures
    • A. 

      Peripheral blood flow

    • B. 

      Venous oxygen saturation

    • C. 

      Central arterial flow

    • D. 

      Arterial oxygen saturation

  • 2. 
    When you are ausculating Mrs Rose's chest , you hear low-pitched, coarse sounds primarily on expiration. This best describes
    • A. 

      Rhonchi (or sonorous wheezes)

    • B. 

      Sibilant wheezes

    • C. 

      Crackles

    • D. 

      Pleural friction rub

  • 3. 
    On another patient, Mr Paku you ausculate musical, squeaky sounds bilaterlly in his lung fields.  This is best described as
    • A. 

      Crackles

    • B. 

      Rhonchi (or sonorous wheezes)

    • C. 

      Sibilant wheezes

    • D. 

      Pleural friction rub

  • 4. 
    Your understanding of creps, rales or crackles is
    • A. 

      Indicative of pneumothorax

    • B. 

      Caused by consolidation, mass or atelectasis

    • C. 

      Indicative of a pleral friction rub

    • D. 

      Created when air is moving through smaller air passages narrowed by mucous or pus

  • 5. 
    Auscultation of the lungs should reveal which normal finding?
    • A. 

      Vesicular breath sounds in all lung fields posteriorly

    • B. 

      Bronchial breath sounds heard faintly over the apices of both lungs

    • C. 

      Bronchovesicular breath sounds over the periphery of the posterior chest wall

    • D. 

      No breath sounds heard at the most extreme margins of the anterior and posterior lungs

  • 6. 
    The best technique for checking tactile fremitus is to use the ulnar surface of the hand
    • A. 

      True

    • B. 

      False

  • 7. 
    When percussing over normal lung fields, the sound you would expect to hear would be
    • A. 

      Dull

    • B. 

      Sonorous

    • C. 

      Resonate

    • D. 

      Crackling

  • 8. 
    Mr James, age 75 is admitted to the hospital with shortness of breath(SOB), a temp of 40degrees and substernal chest pain. He has a history of emphysema and a recent upper respiratory infection. You ausultate a low-pitched grating sound over his left anterior chest that persists even when he holds his breath. You suspect which of the following?
    • A. 

      Tension pneumothorax

    • B. 

      Pericardial friction rub

    • C. 

      Plural friction rub

    • D. 

      Consolidation

  • 9. 
    Possible age-related changes which may affect ventilation include
    • A. 

      Loss of elastic fibres in the lungs

    • B. 

      Clacification in the rub cartilage

    • C. 

      Reduced ciliary activity

    • D. 

      All of the above

  • 10. 
    When assessing John C, aged 64, who has chronic obstructive lung disease, the nurse assesses tactile fremitus
    • A. 

      When assissin tactile fremitus, ask the patient to whisper "1,2,3"

    • B. 

      When assissing tactile fremius, use the soft pads of your finger tips

    • C. 

      Fremius is increased in the presence of pneumothorax or chronic obstructive lung disease

    • D. 

      Fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia

  • 11. 
    Which of the following statements regarding percussion is INCORRECT?
    • A. 

      Involves tapping the body lightly as in indirect, direct or immediate percussion, or fist percussion

    • B. 

      Requires the patient to say "99" or "a" during percussion

    • C. 

      Assists in the detection of fluid or air in a cavity

    • D. 

      Enables the determination of postion, size and density of underlying sturctures

  • 12. 
    The nurse notes that thoracic expansion is greater on the left side than the right and -
    • A. 

      Refers the client ot a physician for additional examination

    • B. 

      Documents this as a variation but within normal findings

    • C. 

      Instructs the client to rest bridfly then repeats the examination again

    • D. 

      Asks the client to repeat the numbers "99" while observing chest wall movements

  • 13. 
    You are working with a client who has respiratory disease.  You find that this client is able to breathe only in an upright or standing position.  In charting, you could describe the diffiuclty breathing in any psoition other than an upright or standing positon, or you could use the term for this condition, which is -
    • A. 

      Bradynpnea

    • B. 

      Tachypnea

    • C. 

      Orthopnea

    • D. 

      Eupnea

  • 14. 
    An appropriate nursing intervention for a patient with pneumonia with the nursing diagnoisis of ineffective airway clearance related to thick secretions would be
    • A. 

      Administer oxygen as prescribed to maintain optimal oxygen levels

    • B. 

      Teach the patient how to cough effrectively to bring secretions to the mouth

    • C. 

      Provide analgesics ordered to promote comfort

    • D. 

      Perform postural drainage every hour

  • 15. 
    The posterior tibial pulse may be palpated o the inner (medial) aspect of the ankle -
    • A. 

      True

    • B. 

      False

  • 16. 
    Which of the following indicates the normal location of the apical pulse in an adult?
    • A. 

      Fifth left intercostal space, medial to mid-clavicular line

    • B. 

      Fourth left intercostal space, mid-clavicular line

    • C. 

      Fifth intercostal space, anterior axillary line

    • D. 

      Fourth intercostal space, left sternal border

  • 17. 
    Which of the following statements regarding cardiac landmarks and auscultation is CORRECT?
    • A. 

      Erb's point is located midsternum in the epigastice area

    • B. 

      Listening to heart sounds through clothing may be reliable

    • C. 

      The forward sitting and left lateral decubitus postions aid in detecting murmurs

    • D. 

      The mitral area is in the second left intercostal space

  • 18. 
    To accurately assess the carotid pulse
    • A. 

      Place two fingers of each hand firmly over the right and left temples at the same time

    • B. 

      Palpate firmly with tow fingers in the inguinal space between the navel and sympysis pubis

    • C. 

      Place the fingers gently in the space between the biceps and triceps muscle

    • D. 

      Plapate each carotid pulse independently at the sternocleidomatoid muscle

  • 19. 
    Which of the following statements accurately describes a pulse deficit
    • A. 

      The apical pulse is greater than the radial pulse

    • B. 

      The peripheral pulse is not palpable

    • C. 

      A condition in which the arterial pulse is less than 60 bpm

    • D. 

      The pulse is palpable but easy to obliterate

  • 20. 
    Mr Pain was admitted to coronary care with a diagnosis of myocardial infarction. 2 days follwoing Mr Pain has a temp of 37.9 degress. The nurse should
    • A. 

      Encouirage deep breathing and coughing every 2 hours

    • B. 

      Record the temperature and monitor vital signs at routine intervals

    • C. 

      Auscultate the chest for diminished breath sounds

    • D. 

      Notify the physician immediately about the tempreture

  • 21. 
    Age-related changes that may alter cardiovascular health include
    • A. 

      Decrease in S-A node cells

    • B. 

      Calcification in mitral or aortic valves

    • C. 

      Venous distention

    • D. 

      All of the above

  • 22. 
    Which perpheral pulse may be palpated at the upper surface of the foot?
    • A. 

      Dorsal plantar

    • B. 

      Posterior tibial

    • C. 

      Femoral

    • D. 

      Dorsalis Pedis

  • 23. 
    Cardiac murmurs
    1. may be caused by high flow rates through normal valves
    2. are generally innocent in older adults
    3. may be caused by forward flow of blood through a constricted valve or into a dilated chamber
    4. may be caused by backward flow through a defective or incompetent valve
    • A. 

      1,3,4

    • B. 

      1,2,3

    • C. 

      1,2 only

    • D. 

      3,4 only

  • 24. 
    Increases in the resting pulse rate are associated with all of the following EXCEPT
    • A. 

      Infection and fever

    • B. 

      Decreases in blood pressure secondary to shock

    • C. 

      Sympathomimetic drugs

    • D. 

      Parasympathetic nervous system stimulation

  • 25. 
    When assessing cyanosis, the nurse will utilise which of the following guiding principles?
    • A. 

      Central cyanosis is best identified around the umbilicus

    • B. 

      Central cyanosis may be due to a cold room, venous obstruction, or anxiety

    • C. 

      Sluggish or reduced blood flow contribute to peripheral cyanosis

    • D. 

      Perpheral cyanosis is best identified in the conjuctiva and tongue

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