Multiple Choice Physical Assessment Quiz

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Multiple Choice Physical Assessment Quiz - Quiz

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Questions and Answers
  • 1. 

    How many lobes in the right lung?

    • A.

      3

    • B.

      2

    • C.

      1

    • D.

      4

    Correct Answer
    A. 3
    Explanation
    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.

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  • 2. 

    The anterior chest area that overlies the heart and great vessels is called the?

    • A.

      Precordium

    • B.

      Epicardium

    • C.

      Myocardium

    • D.

      Endocardium

    Correct Answer
    A. Precordium
    Explanation
    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.

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  • 3. 

    The bicuspid, or mitral, valve is located?

    • A.

      Between the left atrium and left ventricle

    • B.

      Between the right atrium and right ventricle

    • C.

      At the beginning of the ascending aorta

    • D.

      At the exit of each ventricle near the great vessels

    Correct Answer
    A. Between the left atrium and left ventricle
    Explanation
    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.

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  • 4. 

    The semilunar valves are located?

    • A.

      At the exit of each ventricle at the beginning of the great vessels

    • B.

      Between the right atrium and the right ventricle

    • C.

      Between the left atrium and the left ventricle

    • D.

      At the beginning of the ascending aorta

    Correct Answer
    A. At the exit of each ventricle at the beginning of the great vessels
    Explanation
    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.

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  • 5. 

    The sinoatrial node of the heart is located on the?

    • A.

      Posterior wall of the right atrium

    • B.

      Anterior wall of the right atrium

    • C.

      Upper intraventricular system

    • D.

      Anterior wall of the left atrium

    Correct Answer
    A. Posterior wall of the right atrium
    Explanation
    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.

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  • 6. 

    The P-wave phase of an electrocardiogram (ECG) represents

    • A.

      Conduction of the impulse throughout the atria

    • B.

      Conduction of the impulse throughout the ventricles

    • C.

      Ventricular repolarization

    • D.

      Ventricular polarization

    Correct Answer
    A. Conduction of the impulse throughout the atria
    Explanation
    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.

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  • 7. 

    During a cardiac examination, the nurse can best hear the S1 heart sound  by placing the stethescope at the clients?

    • A.

      Base of heart

    • B.

      Pulmonic valve area

    • C.

      Apex of the heart

    • D.

      Second left interspace

    Correct Answer
    C. Apex of the heart
    Explanation
    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.

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  • 8. 

    The S4 heart sound ?

    • A.

      Can be heard during systolic

    • B.

      Is often termed ventricular gallop

    • C.

      Is usually due to heart murmur

    • D.

      Can be heard during diastolic

    Correct Answer
    D. Can be heard during diastolic
    Explanation
    The S4 heart sound can be heard during diastolic. This sound occurs just before the S1 heart sound and is caused by the contraction of the atria pushing blood into a stiff or hypertrophic ventricle. It is often associated with conditions such as hypertension, coronary artery disease, and aortic stenosis. The S4 sound is not usually heard in healthy individuals and can be an indicator of underlying heart problems.

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  • 9. 

    An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible ?

    • A.

      Congestive heart failure

    • B.

      Angina

    • C.

      Palpitations

    • D.

      Acute anxiety reactions

    Correct Answer
    B. Angina
    Explanation
    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.

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  • 10. 

    An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart f disease is?

    • A.

      High serum level of low density lipoproteins

    • B.

      Low carb diet

    • C.

      High serum level of high density lipoprotein

    • D.

      Diets that are high in antioxidant vitamins

    Correct Answer
    A. High serum level of low density lipoproteins
    Explanation
    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.

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  • 11. 

    The nurse is planning a presentation about coronary heart disease for a group of middle-aged adults. Which of the following should be included in the nurses teaching plan ?

    • A.

      Hispanic client have a higher incidence of chd then black or white Americans

    • B.

      The incidence of hypertension in the white population of the UN is greater then black population

    • C.

      Women are most likely to have serious stenosis after heart attack

    • D.

      Estrogen replacement therapy in post menopausal women decreases the risk of heart attacks

    Correct Answer
    D. Estrogen replacement therapy in post menopausal women decreases the risk of heart attacks
    Explanation
    Estrogen replacement therapy in postmenopausal women decreases the risk of heart attacks. This should be included in the nurse's teaching plan because it is important information for middle-aged adults to know. Estrogen replacement therapy can help reduce the risk of heart disease in women who have gone through menopause. This therapy can have a positive impact on their cardiovascular health and should be discussed as a potential preventive measure.

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  • 12. 

    The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. The nurse anticipates that there may be some difficultly palpating the clients?

    • A.

      Apical pulse

    • B.

      Breathe sounds

    • C.

      Jugular veins

    • D.

      Carotid arteries

    Correct Answer
    A. Apical pulse
    Explanation
    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.

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  • 13. 

    The nurse is planning to auscultate a female adult clients carotid arteries. The nurse should plan to ?

    • A.

      Ask the client to hold her breath

    • B.

      Palmate the arteries before auscultation

    • C.

      Place the diaphragm of the stethescope over the artery

    • D.

      Ask the client to breathe normally

    Correct Answer
    A. Ask the client to hold her breath
    Explanation
    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.

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  • 14. 

    While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is?

    • A.

      A normal sound heard in adult clients

    • B.

      A wheezing sound

    • C.

      Associated with occlusive arterial disease

    • D.

      Heard when the artery is almost totally occluded

    Correct Answer
    C. Associated with occlusive arterial disease
    Explanation
    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.

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  • 15. 

    The nurse assesses a hospitalized adult client and observes that the clients jugular veins are fully extended. The nurse contacts the clients physician because the clients signs are indicative of ?

    • A.

      Pulmonary emphysema

    • B.

      Diastolic murmurs

    • C.

      Patent ductus arteriosus

    • D.

      Increased central venous pressure

    Correct Answer
    D. Increased central venous pressure
    Explanation
    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.

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  • 16. 

    While palpating the apex, left sternal border, the base in an adult client , the nurse detects a thrill. The nurse should further assess the client for?

    • A.

      Cardiac murmur

    • B.

      Left side heart failure

    • C.

      Constrictive pericarditis

    • D.

      Congestive heart failure

    Correct Answer
    A. Cardiac murmur
    Explanation
    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.

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  • 17. 

    The nurse is auscultating the heart sounds of an adult client . To auscultate erbs point the nurse should place the stethescope at he ?

    • A.

      Second intercostal space at right sternal border

    • B.

      Third to fifth intercostal spacecraft the left sternal border

    • C.

      Apex of they heart near the midclavicular Line mcl

    • D.

      Fourth or fifth intercostal space at the left lower sternal bored

    Correct Answer
    B. Third to fifth intercostal spacecraft the left sternal border
    Explanation
    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.

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  • 18. 

    While auscultating an adult clients heart rate and rhythm , the nurse detects a irregular pattern . The nurse should 

    • A.

      Assess the client for signs and symptoms of pulmonary disease

    • B.

      Document this as normal findings

    • C.

      Schedule client for an ECG

    • D.

      Refer client to a physician

    Correct Answer
    D. Refer client to a physician
    Explanation
    The nurse should refer the client to a physician because an irregular heart rate and rhythm could be indicative of a cardiac arrhythmia or other underlying heart condition. It is important for the client to receive further evaluation and potentially treatment from a physician to ensure their heart health is properly assessed and managed.

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  • 19. 

    The nurse has assessed the heart sounds of an adolescent client n detects the presense of an S3 heart sound at the beginning of the diastolic pause. The nurse should instruct the client that she should?

    • A.

      Be referred to a cardiologist for further evaluation

    • B.

      Be examined again in 6 months

    • C.

      Restrict exercise and strenuous activities

    • D.

      Recognize that this finding is normal in adolescents

    Correct Answer
    D. Recognize that this finding is normal in adolescents
    Explanation
    The presence of an S3 heart sound at the beginning of the diastolic pause is a normal finding in adolescents. An S3 heart sound is commonly heard in young individuals due to the rapid filling of the ventricles during diastole. It is not indicative of any abnormality or pathology in this age group. Therefore, the nurse should instruct the client to recognize that this finding is normal in adolescents.

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  • 20. 

    While assessing an adult client , the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of?

    • A.

      Pulmonary hypertension

    • B.

      Aortic stenosis

    • C.

      Mitral valve stenosis

    • D.

      Pulmonary hypotension

    Correct Answer
    C. Mitral valve stenosis
    Explanation
    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.

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  • 21. 

    The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that a paradoxical pulses are usually indicative of?

    • A.

      Obstructive lung disease

    • B.

      Left sided heart failure

    • C.

      Premature ventricular contractions

    • D.

      Aortic stenosis

    Correct Answer
    A. Obstructive lung disease
    Explanation
    Paradoxical pulses, also known as pulsus paradoxus, refer to a decrease in systolic blood pressure during inspiration. This can be indicative of obstructive lung disease, such as asthma or chronic obstructive pulmonary disease (COPD). In these conditions, airway obstruction causes increased intrathoracic pressure during inspiration, leading to a decrease in blood flow to the heart and subsequently a decrease in blood pressure. Therefore, the nurse should explain to the client that paradoxical pulses are usually indicative of obstructive lung disease.

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  • 22. 

    The nurse is assessing an adult client with a diagnosis of sinus arrhythmia. The nurse should explain to the client that this indicates that the?

    • A.

      Heartbeats are followed by a pause

    • B.

      Ventricular contraction occurs irregularly

    • C.

      S1 andS2 sounds are both split

    • D.

      Heart rate speeds up and slows down during a cycle

    Correct Answer
    D. Heart rate speeds up and slows down during a cycle
    Explanation
    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.

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  • 23. 

    The fourth heart sound S4 is a/an?

    • A.

      Low frequency sound best heard with the bell of the stethescope

    • B.

      Abnormal findings in trained athletes

    • C.

      Sound that can be heard in the Absence of atrial contractions

    • D.

      Sound that may increase during expiration

    Correct Answer
    C. Sound that can be heard in the Absence of atrial contractions
    Explanation
    The fourth heart sound S4 is a sound that can be heard in the absence of atrial contractions. This sound is caused by the filling of the ventricles against a stiff or noncompliant ventricular wall. It occurs just before the first heart sound (S1) and is often associated with conditions such as hypertension, coronary artery disease, and heart failure. It is typically a low frequency sound and is best heard with the bell of the stethoscope.

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  • 24. 

    The major artery that supplies blood tot he arm is the?

    • A.

      Radial artery

    • B.

      Ulnar artery

    • C.

      Posterior artery

    • D.

      Brachial artery

    Correct Answer
    D. Brachial artery
    Explanation
    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.

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  • 25. 

    The popliteal artery can be palpated at the?

    • A.

      Knee

    • B.

      Great toe

    • C.

      Ankle

    • D.

      Inguinal ligament

    Correct Answer
    A. Knee
    Explanation
    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.

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  • 26. 

    The posterior tibial pulse can be palpated at the ?

    • A.

      Great toe

    • B.

      Knee

    • C.

      Top of foot

    • D.

      Ankle

    Correct Answer
    D. Ankle
    Explanation
    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.

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  • 27. 

    Blood from the lower trunk and legs drain upwards into the inferior vena cava. The percentage of the body's blood volume that is contained in the viens is nearly?

    • A.

      50 %

    • B.

      60%

    • C.

      70%

    • D.

      80%

    Correct Answer
    C. 70%
    Explanation
    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%.

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  • 28. 

    While assessing the peripheral vascular system of an adult client. the nurse detects cold clammy skin and loss of hair on the clients legs. The nurse suspects that the client may be experiencing?

    • A.

      Venous stasis

    • B.

      Varicose veins

    • C.

      Thrombpphlebitis

    • D.

      Arterial insufficiency

    Correct Answer
    D. Arterial insufficiency
    Explanation
    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.

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  • 29. 

    During a physical examination, the nurse detects warm skin and brown pigmentation around an adult clients ankles. The nurse suspects that the client may be experiencing?

    • A.

      Venous insufficiency

    • B.

      Arterial occlusive disease

    • C.

      Venous ulcers

    • D.

      Ankle edema

    Correct Answer
    A. Venous insufficiency
    Explanation
    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.

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  • 30. 

    The nurse is assessing the peripheral vascular  system of an older adult client, the client tells the nurse that her legs  "seem cold all the time and sometimes feel tingly". the nurse suspects that the client may be experiencing?

    • A.

      Varicose veins

    • B.

      Intermittent claudication

    • C.

      Edema

    • D.

      Thrombophlebitis

    Correct Answer
    B. Intermittent claudication
    Explanation
    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.

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  • 31. 

    The nurse is caring for  a client who is employed  as a typist and has a family history of peripheral vascular disease. The nurse should instruct  the client to reduce  her risk factors by?

    • A.

      Eating a high protein diet

    • B.

      Resting frequency

    • C.

      Drinking large quantities of milk

    • D.

      Getting regular exercise

    Correct Answer
    D. Getting regular exercise
    Explanation
    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.

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  • 32. 

    The nurse is preparing to use a Doppler  ultra sound probe to detect blood flow in the femoral artery of an adult client, The nurse should?

    • A.

      Apply K-Y jelly to the clients skin

    • B.

      Place the client in the supine position with the head flat

    • C.

      Place the tip of the probe in a 30 degree angle to the artery

    • D.

      Apply gel used for ECG to the clients skin

    Correct Answer
    A. Apply K-Y jelly to the clients skin
    Explanation
    To use a Doppler ultrasound probe to detect blood flow in the femoral artery, the nurse should apply K-Y jelly to the client's skin. This is because K-Y jelly acts as a lubricant, allowing the probe to glide smoothly over the skin and reducing friction. This ensures optimal contact between the probe and the skin, enabling accurate and clear detection of blood flow in the artery. Applying K-Y jelly also helps to create a seal between the probe and the skin, preventing any air gaps that could interfere with the ultrasound waves.

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  • 33. 

    A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for?

    • A.

      Lymphedema

    • B.

      Raynauds disease

    • C.

      Poor peripheral pulses

    • D.

      Bruits over the radial artery

    Correct Answer
    A. Lymphedema
    Explanation
    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.

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  • 34. 

    After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the clients?

    • A.

      Femoral pulse

    • B.

      Popliteal pulse

    • C.

      Brachial pulse

    • D.

      Tibial pulse

    Correct Answer
    C. Brachial pulse
    Explanation
    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.

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  • 35. 

    The nurse preparing to palpate  the epitrochlear lymph nodes of an adult male client, The nurse should instruct  the client to?

    • A.

      Assume a supine position

    • B.

      Rest his arm on the examination table

    • C.

      Flex his elbow about 90 degrees

    • D.

      Make a fist with his left hand

    Correct Answer
    C. Flex his elbow about 90 degrees
    Explanation
    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.

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  • 36. 

    While inspecting the skin color of a male clients legs, the nurse observes that the clients legs are slightly cyanotic while he is sitting on the edge of the examination table. The nurse should refer the client to a physician for possible?

    • A.

      Arterial insufficiency

    • B.

      Congestive heart failure

    • C.

      Raynauds disease

    • D.

      Venous insufficiency

    Correct Answer
    D. Venous insufficiency
    Explanation
    The nurse should refer the client to a physician for possible venous insufficiency. Cyanosis is a bluish discoloration of the skin that occurs when there is a decrease in oxygen saturation in the blood. In this case, the cyanosis is observed in the client's legs, indicating a potential problem with venous circulation. Venous insufficiency occurs when the veins in the legs are unable to adequately return blood back to the heart, leading to pooling of blood and a decrease in oxygen supply. Therefore, it is important for the nurse to refer the client to a physician for further evaluation and treatment.

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  • 37. 

    While assessing the inguinal nodes in an older adult client, the nurse detects that the lymphs nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician  because these findings are generally associated with?

    • A.

      Localized infection

    • B.

      Systemic infection

    • C.

      Arterial insufficiency

    • D.

      Malignancy

    Correct Answer
    D. Malignancy
    Explanation
    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.

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  • 38. 

    The nurse plans to assess and adult client for Homan's sign. the nurse should?

    • A.

      Ask the client to remain standing for the procedure

    • B.

      Place the hand on the clients thigh muslce

    • C.

      Place the hands near the clients ankle

    • D.

      Flex the clients knee, then dorsiflex the foot

    Correct Answer
    D. Flex the clients knee, then dorsiflex the foot
    Explanation
    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.

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  • 39. 

    The nurse is planning to perform the trendelenburg test on an adult client, the nurse should explain to the client that this test is used to determine the?

    • A.

      Degree of arterial occlusion exits

    • B.

      Pulse of a client with poor elasticity

    • C.

      Competence of the saphenous vein valve

    • D.

      Severity of thrombophlebitis

    Correct Answer
    C. Competence of the saphenous vein valve
    Explanation
    The Trendelenburg test is used to assess the competence of the saphenous vein valve. The test involves elevating the client's leg and applying pressure to the saphenous vein to assess the competency of the valve. If the valve is competent, blood flow will be restricted and the vein will not fill with blood. If the valve is incompetent, blood will flow backwards and the vein will fill with blood. This test helps to determine if there is any venous insufficiency or varicose veins present in the client.

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  • 40. 

    The abdominal contents are enclosed externally by the abdominal wall musculature-three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external?

    • A.

      Rectal abdominis

    • B.

      Transverse abdominis

    • C.

      Abdominal oblique

    • D.

      Umbilical oblique

    Correct Answer
    C. Abdominal oblique
    Explanation
    The correct answer is abdominal oblique because it is one of the three layers of muscle that encloses the abdominal contents externally. The abdominal oblique muscles extend from the back, around the flanks, to the front, providing support and protection to the abdominal organs.

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  • 41. 

    The sigmoid colon is located in this area of the abdomen: The

    • A.

      Left upper quad

    • B.

      Left lower quad

    • C.

      Right upper quad

    • D.

      Left upper quad

    Correct Answer
    B. Left lower quad
    Explanation
    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.

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  • 42. 

    The pancreas of an adult client located ?

    • A.

      Below the diaphragm and extending below the right costal margin

    • B.

      Posterior to the left midiaxillary line and posterior to the stomach

    • C.

      High and deep under the diaphragm and can be palpated

    • D.

      Deep in the upper abdomen and is not normally palpable

    Correct Answer
    D. Deep in the upper abdomen and is not normally palpable
    Explanation
    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.

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  • 43. 

    The primary function of the gall bladder is to ?

    • A.

      Store and excrete bile

    • B.

      Aid in the digestion of protien

    • C.

      Produce alkaline mucus

    • D.

      Produce hormones

    Correct Answer
    A. Store and excrete bile
    Explanation
    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.

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  • 44. 

    The colon originates in this abdominal area: The

    • A.

      Right lower quad

    • B.

      Right upper quad

    • C.

      Left lower quad

    • D.

      Right lower quad

    Correct Answer
    A. Right lower quad
    Explanation
    The correct answer is "right lower quad." The question is asking about the origin of the colon in the abdominal area. The colon is a part of the large intestine and it starts in the right lower quadrant of the abdomen.

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  • 45. 

    To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the clients?

    • A.

      Right upper quad

    • B.

      Right lower quad

    • C.

      Left upper quad

    • D.

      Left lower quad

    Correct Answer
    A. Right upper quad
    Explanation
    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.

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  • 46. 

    To palpate for tenderness of an adult clients appendix, the nurse should begin the abdominal assessment at the clients?

    • A.

      Left upper quad

    • B.

      Left lower quad

    • C.

      Right upper quad

    • D.

      Right lower quad

    Correct Answer
    D. Right lower quad
    Explanation
    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.

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  • 47. 

    To palpate the spleen  of an adult client, the nurse should begin the abdominal assessment of the client at the?

    • A.

      Left lower quad

    • B.

      Left upper quad

    • C.

      Right upper quad

    • D.

      Right lower quad

    Correct Answer
    B. Left upper quad
    Explanation
    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.

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  • 48. 

    The nurse plans to assess an adult clients kidneys for tenderness. The nurse should assess the area of the?

    • A.

      Right upper quad

    • B.

      Left upper quad

    • C.

      External oblique angle

    • D.

      Costovertebral angle

    Correct Answer
    D. Costovertebral angle
    Explanation
    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.

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  • 49. 

    A client visits  the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of?

    • A.

      Stomach ulcers

    • B.

      Pancreatic cancer

    • C.

      Decreased gastric motility

    • D.

      Abdominal tumors

    Correct Answer
    A. Stomach ulcers
    Explanation
    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.

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  • 50. 

    The nurse is assessing an older adult client who has lost 5 pounds since her last visit in 1 year ago. The client tells the nurse that her husband had died 2 months ago. the nurse should further assess the client for?

    • A.

      Peptic ulcers

    • B.

      Bulimia

    • C.

      Appetite changes

    • D.

      Pancreatic disorders

    Correct Answer
    C. Appetite changes
    Explanation
    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.

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Jul 10, 2013
    Quiz Created by
    Meredith31
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