Multiple Choice Physical Assessment Quiz

The gallbladder's primary function is to store and excrete bile. Bile is a substance produced by the liver that helps in the digestion and absorption of fats. The gallbladder stores bile and releases it into the small intestine when needed, especially after a meal that contains fats. This allows for the efficient breakdown and absorption of fats in the digestive system.

The correct answer is "I can decrease the constipation if I eat foods high in fiber and drink water." This answer demonstrates that the client understands the nurse's instructions about managing constipation caused by iron tablets. Eating foods high in fiber and drinking water can help soften the stool and promote regular bowel movements, thus alleviating constipation. This response shows that the client is aware of the importance of dietary modifications in managing constipation while continuing to take iron tablets for anemia.

Before assessing the abdomen of an adult male client, it is important for the nurse to ask the client to empty his bladder. This is because a full bladder can interfere with the accuracy of the assessment. The bladder can push against the abdominal organs, causing discomfort and potentially affecting the nurse's ability to palpate and assess the abdomen properly. By asking the client to empty his bladder, the nurse ensures that the assessment can be conducted effectively and accurately.

The nurse should refer the client to a physician for possible umbilical hernia. An umbilical hernia occurs when part of the intestine or abdominal tissue protrudes through the umbilical opening in the abdominal wall. The enlargement and eversion of the umbilicus are characteristic signs of an umbilical hernia. Referring the client to a physician is important for further evaluation and appropriate management of the hernia.

The client's symptoms of chest pain and pain down the left arm are classic signs of angina, which is caused by reduced blood flow to the heart. Angina is often a warning sign of underlying heart disease and should not be ignored. Referring the client to a physician for further evaluation and possible treatment is the appropriate course of action in this situation.

The popliteal artery can be palpated at the knee because it is located behind the knee joint. Palpation of the popliteal artery at this location allows for assessment of its pulsation and can provide important information about the blood flow to the lower leg and foot.

Regular exercise is important for reducing the risk factors of peripheral vascular disease. Exercise helps to improve blood circulation, strengthen the heart and blood vessels, and maintain a healthy weight. It also helps to lower blood pressure and cholesterol levels, which are common risk factors for peripheral vascular disease. Therefore, getting regular exercise is a crucial recommendation for the client to reduce her risk factors.

Bright hematemesis refers to the vomiting of bright red blood, which indicates active bleeding in the upper gastrointestinal tract. Stomach ulcers are a common cause of upper gastrointestinal bleeding. Therefore, the nurse should refer the client to a physician because bright hematemesis is indicative of stomach ulcers.

The bicuspid, or mitral, valve is located between the left atrium and left ventricle. This valve prevents the backflow of blood from the left ventricle into the left atrium during ventricular contraction, ensuring that blood flows in one direction, from the atrium to the ventricle.

The brachial artery is the major artery that supplies blood to the arm. It is located in the upper arm and runs along the inside of the arm, close to the bicep muscle. The brachial artery branches off from the subclavian artery in the shoulder and continues down the arm, giving off smaller branches that supply blood to the muscles and tissues of the arm. It is responsible for delivering oxygenated blood to the arm and is an important pathway for the circulation of nutrients and removal of waste products.

The posterior tibial pulse can be palpated at the ankle. The posterior tibial artery runs behind the medial malleolus (inner ankle bone) and can be felt by pressing gently on this area. Palpating the pulse at the ankle is a common method used to assess blood flow in the lower extremities.

After undergoing a mastectomy, a client is at risk for developing lymphedema, which is the accumulation of lymph fluid in the tissues, leading to swelling and discomfort. This can occur due to the disruption of lymphatic vessels during surgery. Therefore, the nurse should assess the client for any signs or symptoms of lymphedema, such as swelling, heaviness, or tightness in the affected area. Raynaud's disease, poor peripheral pulses, and bruits over the radial artery are not directly related to a mastectomy and would not be the priority assessment in this case.

The right lung has three lobes. The lungs are divided into lobes, with the right lung having three lobes (upper, middle, and lower) and the left lung having two lobes (upper and lower). Each lobe is further divided into smaller sections called bronchopulmonary segments. The lobes of the lungs play a crucial role in the respiratory system by allowing the exchange of oxygen and carbon dioxide during breathing.

The correct answer is Precordium. The precordium is the area of the chest that overlies the heart and great vessels. It includes the sternum, ribs, and the area between the lungs. It is an important area for assessing cardiac function and can provide valuable information about the heart's position, size, and any abnormal sounds or vibrations. The epicardium, myocardium, and endocardium are all layers of the heart itself, but they do not specifically refer to the anterior chest area.

When the jugular veins are fully extended, it indicates increased central venous pressure. The jugular veins are located in the neck and are directly connected to the superior vena cava, which carries deoxygenated blood from the upper body to the heart. When there is increased pressure in the central venous system, the jugular veins become distended and can be seen bulging. This can be a sign of fluid overload, heart failure, or obstruction in the venous system. The nurse contacts the physician because this finding requires further assessment and intervention.

After palpating the radial pulse and suspecting arterial insufficiency, the nurse should next assess the brachial pulse. The brachial pulse is located in the upper arm and is commonly used to assess blood flow to the arms. By assessing the brachial pulse, the nurse can further evaluate the arterial circulation in the client's upper extremities and gather more information about the potential arterial insufficiency.

The sigmoid colon is located in the left lower quadrant of the abdomen. This is the area of the abdomen that is situated on the left side and below the level of the umbilicus (belly button). The sigmoid colon is the S-shaped portion of the large intestine that connects the descending colon to the rectum. It is positioned in the left lower quadrant due to its anatomical location within the abdominal cavity.

The nurse should refer the client to a physician for possible paralytic ileus. Paralytic ileus is a condition where there is a temporary paralysis of the intestines, leading to a lack of bowel sounds. This can be caused by various factors such as surgery, medication side effects, or underlying medical conditions. It is important for the client to be evaluated by a physician to determine the cause of the absence of bowel sounds and to receive appropriate treatment.

The nurse should further assess the client for appetite changes. The client's recent weight loss and the recent death of her husband may be indicators of changes in her appetite. Grief and emotional distress can often affect a person's appetite, leading to weight loss or changes in eating habits. By assessing for appetite changes, the nurse can determine if the client's weight loss is related to emotional factors or if there may be underlying medical conditions contributing to the weight loss.

To assess for Homan's sign, the nurse should flex the client's knee and then dorsiflex the foot. Homan's sign is a test for deep vein thrombosis (DVT) in the leg. Flexing the knee and dorsiflexing the foot causes tension on the calf muscles, which can elicit pain in the presence of a DVT. This test should be performed with caution, as it can dislodge a blood clot and cause complications. The other options mentioned in the question are incorrect and not related to assessing for Homan's sign.

The nurse can best hear the S1 heart sound by placing the stethoscope at the apex of the heart. The apex is the lower tip of the heart, which is located at the fifth intercostal space in the midclavicular line. This is the area where the mitral valve is best heard, and the S1 heart sound is produced by the closure of the mitral and tricuspid valves. Placing the stethoscope at the apex allows for optimal auscultation of this sound.

The priority nursing diagnosis for this client is "disturbed body image related to temporary colostomy." This is because the client's refusal to look at the colostomy bag or area suggests that she may be experiencing negative feelings or discomfort about her changed body image. The nurse should prioritize addressing these concerns and providing support to help the client adjust to and accept her temporary colostomy.

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's right upper quadrant. The liver is located in the right upper quadrant of the abdomen, just below the diaphragm. Percussion is a technique used to assess the density and resonance of organs by tapping on the body surface. By starting in the right upper quadrant, the nurse can accurately locate and assess the liver.

The P-wave phase of an electrocardiogram (ECG) represents the conduction of the impulse throughout the atria. The atria are the upper chambers of the heart responsible for receiving blood from the veins and pumping it into the ventricles. The P-wave on the ECG represents the depolarization (contraction) of the atria as the electrical signal spreads through them. This is followed by the QRS complex, which represents the conduction of the impulse throughout the ventricles, and the T-wave, which represents ventricular repolarization.

The nurse suspects that the client may be experiencing arterial insufficiency because cold clammy skin and loss of hair on the legs are symptoms commonly associated with this condition. Arterial insufficiency occurs when there is a decrease in blood flow to the extremities, often due to blockages or narrowing of the arteries. This can result in decreased oxygen and nutrient supply to the tissues, leading to symptoms such as cold and clammy skin, hair loss, and poor wound healing. Venous stasis, varicose veins, and thrombophlebitis are conditions that primarily affect the veins and would not typically present with these symptoms.

The nurse should refer the client to a physician for possible masses. Deviation of the umbilicus to the left can be a sign of an underlying mass or tumor in the abdomen. It is important for the client to be evaluated by a physician to determine the cause of the deviation and to initiate appropriate treatment if necessary.

High serum levels of low-density lipoproteins (LDL) are a risk factor for coronary heart disease. LDL is often referred to as "bad" cholesterol because it can build up in the arteries, leading to plaque formation and narrowing of the blood vessels. This can increase the risk of a coronary artery becoming blocked, resulting in a heart attack. Therefore, it is important for the nurse to explain to the client that having high levels of LDL in the blood can increase their risk of developing coronary heart disease.

To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's right lower quadrant. The appendix is located in the lower right quadrant of the abdomen, so this is the area where tenderness would most likely be felt if there is inflammation or infection in the appendix. Starting the assessment in this area allows the nurse to gather important information about the client's condition and determine if further investigation or medical intervention is necessary.

A bruit is a sound that is heard over a blood vessel, such as the carotid artery, and is typically associated with occlusive arterial disease. This means that there may be a blockage or narrowing of the artery, which can lead to reduced blood flow. Detecting a bruit in an older adult client suggests that there may be a potential issue with their arterial health and further assessment or intervention may be needed.

After abdominal surgery, it is important for the nurse to inspect the abdomen area to assess for any signs of infection, inflammation, or wound healing. Inspecting the abdomen allows the nurse to observe the incision site for any redness, swelling, or drainage, which could indicate a potential complication. This initial assessment helps the nurse to gather important information about the client's condition and determine the next course of action. Palpating the incision site, auscultating for bowel sounds, and percussing for tympany may be done later in the assessment process, but inspecting the abdomen area is the first step in the assessment.

The spleen is located in the left upper quadrant of the abdomen. Therefore, to palpate the spleen, the nurse should begin the abdominal assessment of the client at the left upper quadrant.

The nurse should refer the client to a physician for possible intestinal obstruction. High pitched tingling sounds throughout the distended abdomen can indicate bowel obstruction. This occurs when there is a blockage in the intestines that prevents the normal flow of food, fluid, and gas. It can cause symptoms such as abdominal pain, bloating, and constipation. Prompt medical attention is necessary to diagnose and treat the condition to prevent further complications.

When a nurse detects a thrill while palpating the apex, left sternal border, and the base in an adult client, it indicates the presence of a cardiac murmur. A thrill is a palpable vibration that can be felt over the chest and is often associated with turbulent blood flow caused by a heart valve abnormality. Therefore, the nurse should further assess the client for signs and symptoms of a cardiac murmur, such as abnormal heart sounds, shortness of breath, fatigue, and chest pain.

To auscultate Erb's point, the nurse should place the stethoscope at the third to fifth intercostal space at the left sternal border. Erb's point is located in this area and is the best location to hear the sounds of the aortic and pulmonic valves. It is important for the nurse to accurately place the stethoscope in order to properly assess the client's heart sounds.

The nurse should assess the costovertebral angle to check for kidney tenderness. The costovertebral angle is located on the back, just below the ribcage, where the ribs meet the spine. This area is in close proximity to the kidneys, making it an appropriate location to assess for tenderness or pain. Assessing the right or left upper quadrant or the external oblique angle would not be as relevant for assessing kidney tenderness.

Emphysema is a chronic lung disease characterized by the destruction of the alveoli, leading to decreased lung function. This can result in a hyperinflated chest and a barrel-shaped chest wall, making it difficult to palpate the apical pulse accurately. The apical pulse is typically assessed by placing the stethoscope over the apex of the heart, which may be difficult due to the altered chest shape in individuals with emphysema. Therefore, the nurse anticipates having difficulty palpating the apical pulse in this client.

The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels. This means that they are situated between the ventricles and the major arteries that carry blood away from the heart, such as the pulmonary artery and the aorta. These valves prevent the backflow of blood into the ventricles when the heart relaxes and ensure that blood flows in the correct direction, from the ventricles into the arteries.

The nurse suspects that the client may be experiencing intermittent claudication. Intermittent claudication is a condition characterized by pain, cramping, or fatigue in the muscles of the legs during physical activity, such as walking. This is caused by reduced blood flow to the muscles due to narrowed or blocked arteries. The client's complaint of cold legs and tingling sensations could be indicative of poor circulation, which is commonly associated with intermittent claudication.

The nurse should refer the client to a physician because lymph nodes that are approximately 3 cm in diameter, nontender, and fixed are generally associated with malignancy. These characteristics suggest that the lymph nodes may be enlarged due to the presence of cancer cells. It is important for the client to be evaluated by a physician to determine the cause of the lymph node enlargement and to initiate appropriate treatment if necessary.

The warm skin and brown pigmentation around the client's ankles suggest venous insufficiency. This condition occurs when the veins in the legs are unable to properly return blood to the heart, leading to pooling of blood and increased pressure in the veins. The warm skin is a result of increased blood flow and the brown pigmentation is caused by the breakdown of red blood cells and the release of iron deposits. These symptoms are characteristic of venous insufficiency rather than arterial occlusive disease, venous ulcers, or ankle edema.

The nurse should refer the client to a physician for possible internal bleeding because purple discoloration at the flanks can be a sign of bruising caused by bleeding under the skin. Internal bleeding can be a serious condition that requires prompt medical attention to identify the cause and provide appropriate treatment.

To assess for rebound tenderness, the nurse should palpate deeply while quickly releasing pressure. Rebound tenderness is a sign of peritoneal irritation and is assessed by applying pressure to the abdomen and then quickly releasing it. If the client experiences pain when the pressure is released, it indicates rebound tenderness. Palpating lightly or performing the assessment first may not provide accurate results, and asking the client to assume a side lying position is not necessary for this specific assessment.

The correct answer is the posterior wall of the right atrium. The sinoatrial node, also known as the natural pacemaker of the heart, is responsible for initiating the electrical impulses that regulate the heart's rhythm. It is located in the upper part of the posterior wall of the right atrium, near the opening of the superior vena cava.

Blood from the lower trunk and legs drains upwards into the inferior vena cava, which is a large vein that carries deoxygenated blood from the lower body back to the heart. Veins are responsible for returning blood to the heart, and they have a larger capacity than arteries. Therefore, a significant portion of the body's blood volume is contained in the veins. The correct answer is 70%.

Opening snaps early in diastole during auscultation of the heart are usually indicative of mitral valve stenosis. Mitral valve stenosis is a condition where the mitral valve, which separates the left atrium and left ventricle, becomes narrowed. This narrowing restricts blood flow from the left atrium to the left ventricle, causing turbulent blood flow and producing the opening snaps. This condition can lead to symptoms such as fatigue, shortness of breath, and fluid retention. It is important for the client to be referred to a physician for further evaluation and management of mitral valve stenosis.

To palpate the spleen of an adult client, the nurse should place the right hand below the left costal margin. This is because the spleen is located in the upper left quadrant of the abdomen, just below the left costal margin. By placing the right hand below the left costal margin, the nurse can effectively feel for any enlargement or abnormalities in the spleen. This technique allows for better access and accuracy in palpating the spleen compared to other options provided in the question.

When auscultating the carotid arteries, it is important for the nurse to ask the client to hold her breath. This is because the sound of the client's breathing can interfere with the nurse's ability to hear the arterial sounds clearly. By asking the client to hold her breath, the nurse can ensure a more accurate assessment of the carotid arteries.

To palpate the epitrochlear lymph nodes, the nurse should instruct the client to flex his elbow about 90 degrees. Flexing the elbow helps to relax the muscles and makes it easier to locate and palpate the lymph nodes in the groove between the biceps and triceps muscles. This position also provides better access and visibility for the nurse during the examination. Assuming a supine position, resting the arm on the examination table, and making a fist with the left hand are not necessary for palpating the epitrochlear lymph nodes.

Sinus arrhythmia is a normal variation in heart rate where the heart rate speeds up and slows down during a cycle. This means that the client's heart rate is not constant but fluctuates in a regular pattern. It is important for the nurse to explain this to the client so that they understand that their condition is not abnormal or concerning.

The pancreas is located deep in the upper abdomen and is not normally palpable. This means that it is situated in the upper part of the abdomen, behind the stomach, and cannot be felt or touched during a physical examination.