Nursing The Person With Althered Physical Health Bn805

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  • 1/64 Questions

    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 -

    • Bradynpnea
    • Tachypnea
    • Orthopnea
    • Eupnea
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About This Quiz

This quiz for 'Nursing the person with altered physical health BN805' assesses key competencies in respiratory assessment techniques, including understanding and identifying different lung sounds, pulse oximetry, and tactile fremitus. It is essential for nursing students and professionals aiming to enhance patient care skills.

Nursing The Person With Althered Physical Health Bn805 - Quiz

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  • 2. 

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

    • Administer oxygen as prescribed to maintain optimal oxygen levels

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

    • Provide analgesics ordered to promote comfort

    • Perform postural drainage every hour

    Correct Answer
    A. Teach the patient how to cough effrectively to bring secretions to the mouth
    Explanation
    Teaching the patient how to cough effectively to bring secretions to the mouth is an appropriate nursing intervention for a patient with pneumonia and ineffective airway clearance related to thick secretions. This intervention helps the patient to effectively clear their airway by coughing and expelling the thick secretions. By teaching the patient the correct technique, they can actively participate in their own care and improve their airway clearance, which can ultimately help in preventing complications and promoting recovery.

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  • 3. 

    To accurately assess the carotid pulse

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

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

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

    • Plapate each carotid pulse independently at the sternocleidomatoid muscle

    Correct Answer
    A. Plapate each carotid pulse independently at the sternocleidomatoid muscle
  • 4. 

    The nurse detects a possible irregularity in the rhythm of a client's pulse and will

    • Count the client's apical pulse for a full minute

    • Record this as normal for the client

    • Use a stethoscope to check the brachial pulse

    • Count the radial pulse again for 15 seconds and multiply by 4

    Correct Answer
    A. Count the client's apical pulse for a full minute
    Explanation
    When a nurse detects a possible irregularity in the rhythm of a client's pulse, counting the client's apical pulse for a full minute is the appropriate action. The apical pulse is measured by placing the stethoscope on the chest over the apex of the heart and counting the number of beats for a full minute. This method provides a more accurate assessment of the heart's rhythm compared to counting the radial pulse. By counting the apical pulse for a full minute, the nurse can gather more comprehensive information about the client's heart rate and rhythm, which can help in identifying any irregularities or abnormalities.

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  • 5. 

    When ausculating heart sounds, what do you assess?

    • Presence of rubs or murmurs

    • Rhythm

    • Rate

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    When auscultating heart sounds, you assess the presence of rubs or murmurs, the rhythm, and the rate. This means that you listen for any abnormal sounds such as rubbing or whooshing sounds, you observe the regularity of the heartbeat, and you determine the number of beats per minute. By assessing all of these factors, you can gather important information about the overall health and function of the heart.

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  • 6. 

    The Glasgow Coma Scale (GCS) is used to evaluate

    • Level of consiousness

    • Orientation

    • Pupil responses

    • Motor dysfunction

    Correct Answer
    A. Level of consiousness
    Explanation
    The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in a person. It evaluates the individual's ability to open their eyes, respond to verbal commands, and demonstrate motor responses. By assessing these factors, healthcare professionals can determine the severity of a brain injury or neurological condition. The GCS helps in monitoring and tracking changes in consciousness over time, allowing for appropriate medical interventions and treatment plans to be implemented.

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  • 7. 

    Where does the hearts electrical stimulus originate from?

    • Sino-atrial node(SA)node

    • Bundle of His

    • Right bundle branch

    • Purkinje fibres

    Correct Answer
    A. Sino-atrial node(SA)node
    Explanation
    The sino-atrial (SA) node is responsible for initiating the electrical stimulus that controls the heart's rhythm. It is located in the right atrium of the heart and acts as the natural pacemaker. The SA node generates electrical impulses that spread through the atria, causing them to contract and pump blood into the ventricles. From there, the electrical signal travels to the Bundle of His, the right bundle branch, and the Purkinje fibers, which distribute the stimulus to the ventricles, causing them to contract and pump blood out of the heart.

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  • 8. 

    Which will you observe each time you check your patients's IV site?

    • Look for moisture and any oozing

    • Make sure the dressing is not loose

    • A, B and D

    • Any bleeding around or on the dressing

    Correct Answer
    A. A, B and D
    Explanation
    When checking a patient's IV site, it is important to observe for moisture and any oozing, as this could indicate a leak or infection. Additionally, one should make sure the dressing is not loose, as a loose dressing can increase the risk of contamination and dislodgement of the IV. Lastly, any bleeding around or on the dressing should be noted, as it could be a sign of a complication or injury at the site. Therefore, the correct answer is A, B, and D.

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  • 9. 

    Your understanding of creps, rales or crackles is

    • Indicative of pneumothorax

    • Caused by consolidation, mass or atelectasis

    • Indicative of a pleral friction rub

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

    Correct Answer
    A. Created when air is moving through smaller air passages narrowed by mucous or pus
    Explanation
    The given correct answer states that creps, rales, or crackles are created when air is moving through smaller air passages narrowed by mucous or pus. This suggests that these abnormal lung sounds are indicative of an obstruction or blockage in the air passages, which could be caused by conditions such as bronchitis, pneumonia, or asthma. This explanation aligns with the medical understanding of creps, rales, and crackles as abnormal lung sounds that occur due to the presence of fluid or inflammation in the airways.

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  • 10. 

    The best technique for checking tactile fremitus is to use the ulnar surface of the hand

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The ulnar surface of the hand is the best technique for checking tactile fremitus because it is the most sensitive area for detecting vibrations in the chest. When the person being examined speaks, these vibrations can be felt through the ulnar surface, providing valuable information about the condition of the lungs and underlying tissues. This technique is commonly used by healthcare professionals to assess for abnormalities such as fluid in the lungs or consolidation.

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  • 11. 

    Possible age-related changes which may affect ventilation include

    • Loss of elastic fibres in the lungs

    • Clacification in the rub cartilage

    • Reduced ciliary activity

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    As individuals age, several changes occur in the respiratory system that can affect ventilation. The loss of elastic fibers in the lungs leads to decreased lung compliance, making it harder for the lungs to expand and contract efficiently. Calcification in the rib cartilage can restrict chest wall movement, further limiting the ability to breathe deeply. Reduced ciliary activity in the respiratory tract impairs the clearance of mucus and debris, increasing the risk of respiratory infections. Therefore, all of the given options - loss of elastic fibers in the lungs, calcification in the rib cartilage, and reduced ciliary activity - can contribute to age-related changes that affect ventilation.

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  • 12. 

    Age-related changes that may alter cardiovascular health include

    • Decrease in S-A node cells

    • Calcification in mitral or aortic valves

    • Venous distention

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    As individuals age, their cardiovascular health can be affected by several changes. Firstly, there may be a decrease in S-A node cells, which are responsible for initiating the electrical signals that regulate heart rhythm. Additionally, calcification can occur in the mitral or aortic valves, which can lead to valve dysfunction and affect blood flow. Lastly, venous distention, or the swelling of veins, can also occur with age, potentially impacting cardiovascular health. Therefore, all of the above changes can alter cardiovascular health as individuals age.

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  • 13. 

    Assessment of the neurogoic system includes the following areas

    • Sensory and motor function, and reflexes

    • Mental and emotional status

    • Cranial nerve assessment

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    The correct answer is "all of the above" because the assessment of the neurogoic system includes evaluating sensory and motor function, reflexes, mental and emotional status, and cranial nerve assessment. This means that in order to fully assess the neurogoic system, all of these areas need to be examined.

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  • 14. 

    When collecting subjective data froma person during a neurological assessment, you will ask about

    • Headaches

    • Tingling or numbness

    • Diffiulty swallowing

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    During a neurological assessment, it is important to collect subjective data from the person to understand their symptoms and potential neurological issues. Headaches can be indicative of various neurological conditions. Tingling or numbness can be a sign of nerve damage or compression. Difficulty swallowing can be a symptom of a neurological disorder affecting the muscles involved in swallowing. Therefore, asking about all of these symptoms is necessary to gather comprehensive subjective data for a neurological assessment.

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  • 15. 

    Which of the following best describes the term localised

    • Occurs at or around the tubing

    • Occurs at or around the IV insertions site

    • A patient in a local hospital

    • The patient is in the area closest to the nurses station

    Correct Answer
    A. Occurs at or around the IV insertions site
    Explanation
    The term "localized" refers to something that occurs in a specific area or region. In this context, it means that something is happening at or around the site where an IV (intravenous) insertion has taken place. This could refer to any symptoms, complications, or reactions that are specific to the area where the IV was inserted.

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  • 16. 

    IV tubing must be changed every 72 hours

    • True

    • False

    Correct Answer
    A. True
    Explanation
    IV tubing must be changed every 72 hours to prevent the risk of infection. Over time, bacteria can grow in the tubing, increasing the chance of contamination and infection. Changing the tubing regularly helps maintain a sterile environment and ensures the safety of the patient receiving the IV fluids. Therefore, the statement is true.

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  • 17. 

    Which perpheral pulse may be palpated at the upper surface of the foot?

    • Dorsal plantar

    • Posterior tibial

    • Femoral

    • Dorsalis Pedis

    Correct Answer
    A. Dorsalis Pedis
    Explanation
    The correct answer is Dorsalis Pedis. The Dorsalis Pedis pulse can be palpated on the upper surface of the foot. This pulse is important for assessing blood flow to the foot and is commonly checked during physical examinations.

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  • 18. 

    Having the client/patient stand with feet together and eyes closed is a test of

    • Cerebellar function

    • Paresthesia

    • Superficial reflexes

    • The trochlear nerve

    Correct Answer
    A. Cerebellar function
    Explanation
    Having the client/patient stand with feet together and eyes closed is a test of cerebellar function. The cerebellum is responsible for coordinating voluntary movements, maintaining balance, and controlling posture. This test, known as the Romberg test, assesses the cerebellum's ability to integrate sensory information from the proprioceptors in the muscles and joints to maintain balance. If the client/patient sways or loses balance with their eyes closed, it suggests dysfunction in the cerebellum.

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  • 19. 

    Normal duration of the PR interval is

    • 3-5 small squares (0.12-0.20 seconds)

    • 7-8 small squares (0.28-0.32 seconds)

    • 6 small squares (0.24 seconds)

    • 1-2 small squares (0.04-0.08 seconds)

    Correct Answer
    A. 3-5 small squares (0.12-0.20 seconds)
    Explanation
    The normal duration of the PR interval is 3-5 small squares (0.12-0.20 seconds). This indicates the time it takes for the electrical signal to travel from the atria to the ventricles in the heart. A PR interval within this range is considered normal and suggests that the conduction system of the heart is functioning properly.

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  • 20. 

    Which of the following statements are true of a hypertonic solution? a) draws water out of the cells and intestitial space and into the intravascular space b) has a higher osmotic pressure than the blood c) has a lower osmotic pressure than the blood d) dextrose 10% and 50% in water are examples of a hypertonic solution

    • A,b,c

    • A, b, d

    • B, c, d

    • A, b, c, d

    Correct Answer
    A. A, b, d
    Explanation
    A hypertonic solution is a solution that has a higher concentration of solutes compared to the cells and interstitial space. This causes the solution to draw water out of the cells and interstitial space and into the intravascular space, resulting in cell shrinkage. Additionally, a hypertonic solution has a higher osmotic pressure than the blood, meaning that it exerts a greater force to draw water towards it. Finally, examples of hypertonic solutions include dextrose 10% and 50% in water. Therefore, the correct statements are a, b, and d.

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  • 21. 

    Pulse oximetry measures

    • Peripheral blood flow

    • Venous oxygen saturation

    • Central arterial flow

    • Arterial oxygen saturation

    Correct Answer
    A. Arterial oxygen saturation
    Explanation
    Pulse oximetry measures arterial oxygen saturation. This is the percentage of oxygen bound to hemoglobin in the arterial blood. It is an important parameter to monitor the oxygen levels in the body and can help in assessing the respiratory and circulatory function. By placing a sensor on a finger, toe, or earlobe, pulse oximetry can quickly and non-invasively provide a measurement of arterial oxygen saturation. It is commonly used in medical settings, especially during surgeries, to ensure that the patient is receiving enough oxygen.

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  • 22. 

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

    • Rhonchi (or sonorous wheezes)

    • Sibilant wheezes

    • Crackles

    • Pleural friction rub

    Correct Answer
    A. Rhonchi (or sonorous wheezes)
    Explanation
    When auscultating Mrs. Rose's chest and hearing low-pitched, coarse sounds primarily on expiration, this indicates the presence of rhonchi (or sonorous wheezes). Rhonchi are caused by airway obstruction due to mucus or other secretions, leading to a turbulent airflow and resulting in low-pitched sounds. These sounds are typically heard more prominently during expiration. Sibilant wheezes, on the other hand, are high-pitched sounds heard during both inspiration and expiration, often associated with asthma or bronchospasm. Crackles are discontinuous, non-musical sounds heard during inspiration and can indicate fluid or inflammation in the lungs. Pleural friction rub is a grating, scratchy sound caused by inflamed pleural surfaces rubbing together, typically heard during both inspiration and expiration.

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  • 23. 

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

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The posterior tibial pulse can be felt on the inner (medial) side of the ankle. This is a true statement.

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  • 24. 

    When the nurse gathers baseline information on a client, the nurse will check the bp in both arms to detect deficits. There should be no more than how many mmHg difference between the two?

    • 15

    • 25

    • 18

    • 10

    Correct Answer
    A. 15
    Explanation
    When the nurse gathers baseline information on a client, checking the blood pressure in both arms is important to detect any deficits. The nurse should look for no more than a 15 mmHg difference between the blood pressure readings in the two arms. This is because a significant difference in blood pressure between the arms could indicate underlying cardiovascular problems or arterial blockages. Therefore, it is crucial for the nurse to assess and compare the blood pressure in both arms to ensure accurate baseline information and identify any potential health issues.

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  • 25. 

    What is the most reliable indicator of a change in neurologic status in a conscious patient?

    • Pupil reaction

    • Motor strength

    • Cranial nerve abnormality

    • Level of consciousness

    Correct Answer
    A. Level of consciousness
    Explanation
    The level of consciousness is the most reliable indicator of a change in neurologic status in a conscious patient. Changes in consciousness, such as confusion, disorientation, or loss of consciousness, can indicate a variety of neurologic conditions or injuries. Monitoring the level of consciousness allows healthcare providers to assess the patient's neurologic function and determine the appropriate course of action. Pupil reaction, motor strength, and cranial nerve abnormalities can also provide valuable information, but they may not be as reliable or sensitive as changes in the level of consciousness.

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  • 26. 

    When percussing over normal lung fields, the sound you would expect to hear would be

    • Dull

    • Sonorous

    • Resonate

    • Crackling

    Correct Answer
    A. Resonate
    Explanation
    When percussing over normal lung fields, the sound you would expect to hear is "resonate." Resonance is the normal sound produced when percussing over healthy lung tissue. This sound indicates that the air-filled lungs are vibrating freely and producing a clear, hollow sound. Dullness, sonorousness, and crackling are not the expected sounds over normal lung fields and may indicate abnormalities such as consolidation, fluid accumulation, or lung tissue damage.

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  • 27. 

    Increases in the resting pulse rate are associated with all of the following EXCEPT

    • Infection and fever

    • Decreases in blood pressure secondary to shock

    • Sympathomimetic drugs

    • Parasympathetic nervous system stimulation

    Correct Answer
    A. Parasympathetic nervous system stimulation
    Explanation
    Increases in the resting pulse rate are associated with infection and fever, decreases in blood pressure secondary to shock, and sympathomimetic drugs. However, parasympathetic nervous system stimulation typically causes a decrease in heart rate, not an increase. Therefore, it is not associated with increases in the resting pulse rate.

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  • 28. 

    An S3 or S4 is generally indicative of heart failure in an adult

    • True

    • False

    Correct Answer
    A. True
    Explanation
    An S3 or S4 heart sound is typically associated with heart failure in adults. These abnormal sounds occur during the filling phase of the cardiac cycle and indicate impaired ventricular function. The S3 sound, also known as a ventricular gallop, is caused by rapid filling of the ventricles and is often heard in conditions such as congestive heart failure. The S4 sound, also known as an atrial gallop, occurs when the atria contract forcefully to push blood into a stiff or hypertrophic ventricle. Therefore, the statement that an S3 or S4 is generally indicative of heart failure in an adult is true.

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  • 29. 

    Mrs Jones has been admitted to your unit complaining of left sided weakness and difficulty speaking.  From the following assessments, identify the data that BEST represents a NURSING assessment

    • Left sided weakness and speech deficit indicates probable stroke

    • Neurological exam reveals partial paralysis and aphasic speech

    • Brain scan shows evidence of a clot in the middle cerebral artery

    • Unable to communicate basic needs and perform hygiene measures with left hand

    Correct Answer
    A. Unable to communicate basic needs and perform hygiene measures with left hand
    Explanation
    The data "unable to communicate basic needs and perform hygiene measures with left hand" represents a nursing assessment because it focuses on the patient's functional abilities and limitations related to their left-sided weakness and difficulty speaking. This information helps the nurse understand the patient's specific needs and develop a care plan to address them.

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  • 30. 

    You are testing the corneal reflex on a 14 year old boy with normal vision. He displays no blinking to corneal touch.  This is an abnormal finding.

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The corneal reflex is a protective reflex that causes blinking in response to any touch or irritation of the cornea. It is mediated by the trigeminal nerve (cranial nerve V). In a normal individual, the corneal reflex should be present and cause blinking when the cornea is touched. However, in this case, the 14-year-old boy with normal vision does not display any blinking to corneal touch, which is an abnormal finding. Therefore, the correct answer is true.

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  • 31. 

    What does the QRS represent?

    • Depolarisation of the ventricles

    • Depolarisation of the Purkinje fibres

    • Depolarisation of the atria septum

    • Repolarisation of the atria

    Correct Answer
    A. Depolarisation of the ventricles
    Explanation
    The QRS complex represents the depolarization of the ventricles. Depolarization is the electrical activation of the heart muscle cells, causing them to contract and pump blood. The QRS complex is observed on an electrocardiogram (ECG) as a series of three waves (Q, R, and S) and indicates the electrical activity in the ventricles. The depolarization of the Purkinje fibers and the atrial septum are not specifically represented by the QRS complex. Repolarization of the atria is represented by the T wave on the ECG.

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  • 32. 

    Which of the folloing are the most common problem with IV therapy

    • Needle is out of place

    • Patient refueses to cooperate

    • Site is red, sore or swollen

    • Both A and C

    Correct Answer
    A. Both A and C
    Explanation
    Both A and C are the most common problems with IV therapy. When the needle is out of place, it can cause difficulties in administering the fluids or medication correctly, leading to ineffective treatment. On the other hand, if the site where the IV is inserted becomes red, sore, or swollen, it indicates an infection or inflammation, which can also hinder the effectiveness of the therapy and potentially cause further complications.

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  • 33. 

    Hypotonic is a term which means that a solution has

    • A higher osmotic pressure than the blood

    • A lower osmotic pressure than the blood

    • The same osmotic presure as blood

    • Ability to carry oxygen to cells

    Correct Answer
    A. A lower osmotic pressure than the blood
    Explanation
    Hypotonic refers to a solution that has a lower osmotic pressure than the blood. Osmotic pressure is the measure of the concentration of solutes in a solution, and a lower osmotic pressure means that the solution has a lower concentration of solutes compared to the blood. This can cause water to move into the cells, potentially leading to cell swelling or bursting.

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  • 34. 

    A person should he able to maintain his/her balance when standing on one foot for

    • 5 seconds on either side

    • 10 seconds on either side

    • An equal length of time on each side

    • 5 seconds on either side and touching one's nose

    Correct Answer
    A. 5 seconds on either side
    Explanation
    A person should be able to maintain their balance when standing on one foot for 5 seconds on either side because this demonstrates good stability and control over their body. Being able to balance equally on both sides indicates a well-developed sense of proprioception and core strength. It also suggests that the person has good coordination and is able to distribute their weight evenly. The ability to touch one's nose while balancing is not mentioned in the question and therefore not relevant to the correct answer.

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  • 35. 

    Which of the following statements accurately describes a pulse deficit

    • The apical pulse is greater than the radial pulse

    • The peripheral pulse is not palpable

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

    • The pulse is palpable but easy to obliterate

    Correct Answer
    A. The apical pulse is greater than the radial pulse
    Explanation
    both apical and radial pulse should be the same

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  • 36. 

    Mary L aged 48 has been taking antihypertnesive medication for 6 months.  Recently she experiences a "near fainting" episode. Whcih of the following statements will best guide the nurse assessing Mary?

    • The nurse should assiss Mary's bp with Mary supine, sitting and standing

    • Bp should be measured in both arms whenver the nurse assesses Mary

    • A fall in systolic pressure of 5-15 mmHg is significant and indicates postural hypotension

    • Causes of postual hypotension are unknown

    Correct Answer
    A. The nurse should assiss Mary's bp with Mary supine, sitting and standing
    Explanation
    The nurse should assess Mary's blood pressure in different positions (supine, sitting, and standing) because this will provide a comprehensive evaluation of her blood pressure and help determine if she has postural hypotension. By assessing her blood pressure in these positions, the nurse can identify any significant changes in systolic pressure, such as a fall of 5-15 mmHg, which would indicate postural hypotension. This information will guide the nurse in understanding the cause of Mary's near fainting episode and developing an appropriate plan of care.

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  • 37. 

    Which of the following statements about using the bell of stethoscope to assess heart sounds is correct?

    • It is ineffective for detecting murmurs or rubs

    • None of these

    • It must be placed lightly on the skin

    • It is most useful for hearing high pictched sounds

    Correct Answer
    A. It must be placed lightly on the skin
    Explanation
    The correct answer is that the bell of the stethoscope must be placed lightly on the skin. The bell is the smaller side of the stethoscope, and it is designed to detect low-frequency sounds such as murmurs or rubs. Placing it lightly on the skin allows for better conduction of these sounds and helps to minimize any interference or distortion. Pressing too hard may dampen the sounds or make it difficult to hear them accurately. Therefore, it is important to use the bell of the stethoscope with a light touch for assessing heart sounds.

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  • 38. 

    Mr Toms aged 28 years was admitted the previous evening following a concussion while playing rugby. The RN asks you the following questions. What are the four qauick elements of a neurological check

    • Orientation,memory, pupils, motor strength

    • Short-term memory, pupils, cranial nerves, vital signs

    • Consciousness, cranial nerves, motor response, pupils

    • Arousal, gag reflex, motor response, pupils

    Correct Answer
    A. Orientation,memory, pupils, motor strength
    Explanation
    The four quick elements of a neurological check are orientation, memory, pupils, and motor strength. These elements are important in assessing the overall neurological function of a patient. Orientation refers to the patient's awareness of person, place, and time. Memory assessment helps determine the patient's ability to retain and recall information. Pupil examination provides information about the function of the cranial nerves and can indicate potential brain injury. Motor strength assessment evaluates the patient's ability to move and control their muscles, which can indicate any motor deficits or abnormalities.

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  • 39. 

    Which of the following indicates the normal location of the apical pulse in an adult?

    • Fifth left intercostal space, medial to mid-clavicular line

    • Fourth left intercostal space, mid-clavicular line

    • Fifth intercostal space, anterior axillary line

    • Fourth intercostal space, left sternal border

    Correct Answer
    A. Fifth left intercostal space, medial to mid-clavicular line
    Explanation
    The correct answer is "fifth left intercostal space, medial to mid-clavicular line." The apical pulse is located at the fifth intercostal space, which is the space between the ribs, on the left side of the chest. It is specifically located medial to the mid-clavicular line, which is an imaginary line drawn vertically down the middle of the clavicle. This is the standard location for measuring the apical pulse in adults.

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  • 40. 

    When taking a bp which of the following is INCORRECT

    • Inflate the cuff 30mmHg above the point at which the radial or brachial pulse disappeared on palpation

    • Remember that a systolic of 100 plus age in years is normal

    • When using a mercury sphygmomanometer, view the meniscus at eye level

    • Support the patients arm at heart level

    Correct Answer
    A. Remember that a systolic of 100 plus age in years is normal
    Explanation
    The statement "remember that a systolic of 100 plus age in years is normal" is incorrect because it is not a universally accepted guideline for determining normal blood pressure. Blood pressure can vary greatly among individuals and is influenced by various factors such as overall health, lifestyle, and medical conditions. Therefore, it is important to consider a range of factors when assessing blood pressure and not rely solely on a formula based on age.

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  • 41. 

    James Feld, aged 67 years, experienced a cerebrovasuclar accident (CBA). He is able to answer yes or no to simple questions, but has difficulty speaking.  His words are difficult to understand, although he continues to make efforts to speak. Mr Feld is most likely experiencing

    • Willis or paraphasia

    • Global aphasia

    • Wernicke's or receptive aphasia

    • Broca's, or motor aphasia

    Correct Answer
    A. Broca's, or motor aphasia
    Explanation
    James Feld's difficulty in speaking, despite being able to answer yes or no to simple questions, suggests that he is experiencing Broca's, or motor aphasia. This condition is characterized by difficulty in producing speech due to damage to the frontal lobe of the brain, specifically Broca's area. It affects the ability to form words and sentences, but comprehension and understanding of language remain intact. This explains why Mr. Feld's words are difficult to understand, but he continues to make efforts to speak.

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  • 42. 

    What does the T wave represent

    • Ventricular depolarisation

    • Atrial repolarisation

    • Ventricular repolarisation

    • Atrial and ventricular repolarisation

    Correct Answer
    A. Ventricular repolarisation
    Explanation
    The T wave on an electrocardiogram represents ventricular repolarization. It shows the recovery of the ventricles after they have contracted during ventricular depolarization. This phase allows the ventricles to relax and prepare for the next heartbeat. The T wave is an important indicator of the electrical activity of the heart and can provide information about the overall health and function of the ventricles.

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  • 43. 

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

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

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

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

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

    Correct Answer
    A. Fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia
    Explanation
    The correct answer explains that fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia. This means that when there is consolidation in the lungs due to lobar pneumonia, the transmission of sound is enhanced, resulting in increased fremitus. This information is relevant when assessing John C, who has chronic obstructive lung disease, as it helps the nurse differentiate between the two conditions based on the tactile fremitus assessment.

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  • 44. 

    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?

    • Tension pneumothorax

    • Pericardial friction rub

    • Plural friction rub

    • Consolidation

    Correct Answer
    A. Pericardial friction rub
    Explanation
    Based on the given information, Mr. James is presenting with symptoms such as shortness of breath, high temperature, substernal chest pain, and a history of emphysema and upper respiratory infection. The low-pitched grating sound heard over his left anterior chest that persists even when he holds his breath suggests a pericardial friction rub. A pericardial friction rub is a classic sign of pericarditis, which is inflammation of the pericardium (the sac surrounding the heart). This condition can cause chest pain and difficulty breathing, which aligns with Mr. James' symptoms.

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  • 45. 

    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

    • Encouirage deep breathing and coughing every 2 hours

    • Record the temperature and monitor vital signs at routine intervals

    • Auscultate the chest for diminished breath sounds

    • Notify the physician immediately about the tempreture

    Correct Answer
    A. Record the temperature and monitor vital signs at routine intervals
    Explanation
    The correct answer is to record the temperature and monitor vital signs at routine intervals. This is because a temperature of 37.9 degrees Celsius is slightly elevated but not significantly high. It is important to monitor the temperature and vital signs regularly to assess for any changes or worsening of the patient's condition. Encouraging deep breathing and coughing every 2 hours may be beneficial for preventing complications such as pneumonia, but it is not specifically indicated in this situation. Auscultating the chest for diminished breath sounds may be relevant in assessing respiratory function, but it is not the most appropriate action to take based solely on an elevated temperature. Notifying the physician immediately about the temperature is not necessary unless there are other concerning symptoms or signs.

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  • 46. 

    When assessing cyanosis, the nurse will utilise which of the following guiding principles?

    • Central cyanosis is best identified around the umbilicus

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

    • Sluggish or reduced blood flow contribute to peripheral cyanosis

    • Perpheral cyanosis is best identified in the conjuctiva and tongue

    Correct Answer
    A. Sluggish or reduced blood flow contribute to peripheral cyanosis
    Explanation
    Sluggish or reduced blood flow contribute to peripheral cyanosis because when blood flow is compromised, there is less oxygenated blood reaching the peripheral tissues. This can occur due to factors such as vasoconstriction, decreased cardiac output, or obstruction of blood vessels. As a result, the tissues in the extremities, such as the fingers, toes, and lips, may appear bluish or cyanotic. Central cyanosis, on the other hand, is caused by decreased oxygen saturation in the arterial blood and is best identified by observing the lips, tongue, and oral mucosa.

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  • 47. 

    An electrocardiogram (ECG) is ordered for Jack who is complaining of chest pain.  An early finding in the lead over an infarction area would be

    • Disappearance of Q waves

    • Flattened T waves

    • Absence of P waves

    • Elevated or depressed ST segments

    Correct Answer
    A. Elevated or depressed ST segments
    Explanation
    An early finding in the lead over an infarction area would be elevated or depressed ST segments. This is because an infarction, which refers to the death of heart muscle tissue due to a lack of blood supply, can cause changes in the electrical activity of the heart. The ST segment on an ECG represents the period between ventricular depolarization and repolarization. In the case of an infarction, the ST segment can become elevated or depressed, indicating abnormal electrical activity in the affected area of the heart. This finding can help diagnose and assess the severity of a heart attack.

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  • 48. 

    Which blood type is the "universal donor"

    • O +

    • O -

    • AB+

    • A -

    Correct Answer
    A. O -
    Explanation
    O- is considered the "universal donor" blood type because it lacks the A or B antigens on the surface of its red blood cells. This means that O- blood can be transfused to individuals with any blood type, as it is less likely to cause an immune reaction. Additionally, O- blood is compatible with both Rh positive and Rh negative blood types, making it suitable for a wider range of recipients.

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  • 49. 

    Which of the following statements regarding percussion is INCORRECT?

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

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

    • Assists in the detection of fluid or air in a cavity

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

    Correct Answer
    A. Requires the patient to say "99" or "a" during percussion
    Explanation
    Percussion is a technique used in physical examination to assess the underlying structures of the body by tapping on the body surface. It can help in detecting fluid or air in a cavity and determining the position, size, and density of underlying structures. However, it does not require the patient to say "99" or "a" during percussion. This statement is incorrect as it does not align with the actual procedure of percussion.

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Quiz Review Timeline (Updated): Mar 21, 2023 +

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  • Current Version
  • Mar 21, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Nov 12, 2013
    Quiz Created by
    TaniaChaney

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