Question 1

The most appropriate method to use to assess for a carotid artery for the presence of a bruit is to:

Accepted Answer

Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle.Have the client turn the head slightly away from the side being examined.Ask the client to hold the breath for a moment so that breath sounds do not obscure a bruit.Normally you do not hear any sounds during carotid auscultation.Palpate the artery lightly for a thrill (palpable bruit)if you hear a bruit.

Question 2

The shift report states that a client has "crackles in both lungs." Which statement by the nurse preparing to assess the client best reflects a thorough understanding of the recorded assessment finding?

Accepted Answer

Crackles are most common in dependent lobes: right and left lung bases,Fine crackles are high-pitched fine,short,interrupted crackling sounds heard during end of inspiration,usually not cleared with coughing.Medium crackles are lower,more moist sounds heard during middle of inspiration;not cleared with coughing and coarse crackles are loud,bubbly sounds heard during inspiration;not cleared with coughing.Reassessing and asking the client to cough provides the clearest understanding of this type of breath sounds.Musical sounds are representative of wheezes not crackles.

Question 3

The shift report states that a client has "crackles in both lungs." Which statement by the nurse,preparing to assess the client,best reflects a thorough understanding of the recorded assessment finding?

Accepted Answer

Crackles are most common in dependent lobes: right and left lung bases.Fine crackles are high-pitched,fine,short,interrupted crackling sounds heard during the end of inspiration and usually not cleared with coughing;medium crackles are lower,more moist sounds heard during the middle of inspiration and not cleared with coughing;and coarse crackles are loud,bubbly sounds heard during inspiration and not cleared with coughing.Reassessing and asking the client to cough provide the clearest understanding of this type of breath sound.Musical sounds are representative of wheezes,not crackles.

Question 4

The primary reason for encouraging a client to urinate before beginning a physical examination is:

Accepted Answer

An empty bladder and bowel facilitate examination of the abdomen,genitalia,and rectum.The remaining options may be plausible reasons,but they are not the primary one.

Question 5

The most appropriate method to use to assess a carotid artery for the presence of a bruit is to:

Accepted Answer

Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle.Have the client turn the head slightly away from the side being examined.Ask the client to hold the breath for a moment so that breath sounds do not obscure a bruit.Normally you do not hear any sounds during carotid auscultation.Palpate the artery lightly for a thrill (palpable bruit)if you hear a bruit.

Question 6

Which of the following statements made by a nursing student regarding assessment technique requires immediate follow-up by the clinical instructor?

Accepted Answer

Do not palpate a vital artery with pressure that obstructs blood flow nor assess both such arteries at the same time since this could result in a dangerous lack of blood flow to the brain.The remaining options are not inaccurate and so do not require immediate follow-up.

Question 7

The nurse recognizes that which of the following clients should be thoroughly assessed for their ability to be safely placed in the supine position?

Accepted Answer

Clients who are experiencing any degree of respiratory distress will not find this position comfortable and should not be placed in this position because it will make breathing even more difficult.If the client becomes short of breath easily,raise the head of the bed.The other clients may not prefer this position,but there is no medical reason for avoiding it.

Question 8

A male nursing student is assigned to change the abdominal dressing of a 74-year-old female.The clinical nursing instructor asks that a female nurse assist him with the procedure.The primary reason for this decision is:

Accepted Answer

When the client and nurse are of opposite gender,it helps to have a third person of the client's gender in the room.The presence of a third person ensures the client that the examiner will behave ethically.This person is also a witness to the examiner's conduct as well as the client's.While a second health care provider may be useful during the assessment and procedure,that is not the primary reason for their presence.

Quiz 33: Health Assessment and Physical Examination