Question 1

The initial assessment of a patient who was admitted with a gastrointestinal inflammatory disease revealed that the patient had hyperactive bowel sounds. The follow-up assessment finds that the bowel sounds are still hyperactive but are now audible without a stethoscope. The nurse will correctly chart:

Accepted Answer

Borborygmus refers to a loud, prolonged, and excessive gurgling stomach sound that is audible to the naked ear. This is the appropriate term to use when bowel sounds are hyperactive and audible without a stethoscope. Choice A refers to normal, low-pitched bowel sounds. Choice C simply states that the bowel sounds are high pitched without providing any additional information. Choice D is redundant as it repeats the initial assessment without add any new information.

Question 2

While assessing the feet of a 72-year-old male patient with diabetes, the nurse noted that there were no cuts, cracks, or blisters. The patient stated, "I don't have as much feeling in my feet as I used to." The nurse correctly understands that the patient is most likely suffering from

Accepted Answer

The patient's lack of feeling in his feet is an indication of paresthesia, which is a common complication of diabetes. Paresthesia refers to a numbness or tingling sensation in the extremities, which can cause a person to be less aware of injuries or wounds. This can lead to delayed treatment and increased risk of infection or necrosis. The absence of cuts, cracks, or blisters is a positive sign that the patient is taking good care of his feet, but his reduced sensation is still cause for concern. Lentigines, which are dark spots on the skin, are not related to this patient's symptoms. Necrosis typically manifests as tissue death and is a severe complication that may result from untreated wounds or infections.

Question 3

A patient tells the nurse that the cardiologist has told her that she will likely need a mitral valve replacement in a few years. The nurse can best hear her mitral valve

Accepted Answer

The mitral valve is best heard over the apex of the left ventricle, which is located on the fifth intercostal space in the midclavicular line. This location corresponds to the point of maximal impulse (PMI) of the heart, which is where the apical pulse can be palpated.

Question 4

A nurse wakes the patient for a focused assessment. The patient, trying to rest, tells the nurse, "I wish you would quit waking me up. Do you really need to keep bothering me?" The nurse appropriately responds:

Accepted Answer

The nurse's response in option D directly addresses the patient's current treatment (new blood pressure medicine) and explains the necessity of the assessment for monitoring potential changes or side effects, making it the most appropriate and patient-centered response.

Question 5

During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

Accepted Answer

It is common for intestinal peristalsis to slow down as a person ages, causing problems with constipation. This can be due to decreased muscle tone, reduced physical activity, medications, and dehydration. It is important to assess for constipation in elderly patients and implement interventions such as increasing fluid and fiber intake, promoting physical activity, and providing stool softeners if necessary. It is not true that elderly patients always abuse laxatives or that they always have difficulty having a bowel movement while hospitalized. While the rectal sphincter may lose elasticity with age, this does not necessarily decrease the sensation of urgency.

Question 6

When performing a physical assessment of a patient, a nurse uses the five techniques of obtaining objective data. The technique that provides data by using the hands is

Accepted Answer

Palpation involves using the hands to gather data about the patient, such as feeling for masses, tenderness, or warmth. Auscultation involves listening with a stethoscope, observation involves visual inspection, and olfaction involves using the sense of smell.

Question 7

The patient's blood pressure at 8:00 a.m. was 124/80 mm Hg, and now at 12:00 p.m., it is 152/94 mm Hg. The charge nurse appropriately instructs the newly hired nurse that

Accepted Answer

Because the patient's blood pressure has become elevated, it should be rechecked in 1 to 2 hours to monitor for any possible hypertensive crisis. Waiting 15 minutes would not be sufficient time for the patient's blood pressure to normalize. Eight hours may be too long of a wait, and there is a reason to recheck the blood pressure due to the significant increase in readings. Therefore, option C is the best choice. Option D is incorrect as it is not safe to assume that the pattern of elevation is typical for the patient without further investigation.

Question 8

The nurse charts that the patient is eupneic. This finding indicates that respirations

Accepted Answer

Eupnea refers to normal, unlabored respiration. It implies that the depth and rate of breathing are within normal ranges, typically without the need for accessory muscle use, which is consistent with option D.

Question 9

At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

Accepted Answer

Measurable signs of illness or injury can be observed and documented using the four senses. This includes things like fever, high blood pressure, rapid breathing, or abnormal sounds in the chest. Subjective symptoms, on the other hand, are what the patient reports they are feeling, such as pain or nausea. These are important to consider, but cannot always be measured objectively. Hidden signs of illness or injury may not be apparent during a physical assessment and require further investigation.

Question 10

A nurse, preparing to auscultate breath sounds, correctly positions the patient in the most favorable position, which is

Accepted Answer

The high Fowler position is the most favorable position for auscultating breath sounds because it allows maximum lung expansion and is the most comfortable position for the patient. This position involves having the patient sitting upright with their legs hanging down, and their arms resting on a table or in their lap.

Question 11

A stable male patient, who was just admitted for left-lower-lobe pneumonia, tells the nurse that his cough is nonproductive. When assessing the patient's breath sounds, the nurse suspects consolidation when, over the left lower lobe, she detects

Accepted Answer

Absent breath sounds suggest consolidation, which is consistent with left-lower-lobe pneumonia. Rales and rhonchi are adventitious breath sounds that are associated with fluid or mucus in the airways, which is not necessarily indicative of consolidation. Stridor is a high-pitched wheezing sound that is typically associated with upper airway obstruction, rather than pneumonia.

Question 12

A male patient has been admitted with congestive heart failure. Although the patient is sitting in a semi-Fowler position, the nurse cannot auscultate distinct heart tones. The nurse will correctly first

Accepted Answer

Having the patient lean forward and toward his left side can help to bring the heart closer to the chest wall, making the heart tones easier to auscultate. The other options may be necessary, but the nurse should first try to improve the ability to auscultate the heart tones before documenting or reporting the findings.

Question 13

A female patient who was admitted after suffering a stroke becomes frustrated because she is unable to respond verbally to the nurse's questions. The nurse, understanding the complications following a stroke, charts that the patient is

Accepted Answer

Aphasia is an impairment of language ability caused by damage to the brain. It can affect a person's ability to speak, understand language, read and write after a stroke or head injury. Dysphasia refers to difficulty with speech, while dysphagia refers to difficulty with swallowing. Dyspnea refers to difficulty breathing.

Question 14

The nurse correctly assesses a patient's abdomen by following the sequence of

Accepted Answer

The correct sequence for abdominal assessment is inspection, auscultation, and palpation. This sequence is important because palpation can stimulate bowel movements, which could alter the sounds you would auscultate if auscultation were done after palpation.

Question 15

The nurse gives the patient the following instructions: "Focus on my pencil and follow it as I move it away from you and then back toward you." The nurse is assessing the

Accepted Answer

By having the patient focus on and follow the pencil as it moves, the nurse is testing the patient's accommodation response, which is the ability of the eyes to adjust focus from far to near objects.

Question 16

A patient who is one day postoperative is complaining of nausea and refusing to eat. Upon auscultation of the abdomen, the nurse finds that the patient's bowel sounds are hypoactive. This is most likely due to

Accepted Answer

Anesthesia can cause temporary slowing of the bowel movements, leading to hypoactive bowel sounds and nausea postoperatively.

Question 17

The nurse correctly uses percussion when assessing the patient for

Accepted Answer

Percussion is used to assess the resonance of lung tissue and is particularly useful in detecting hyperinflated lungs, which would produce a dull or flat sound upon percussion. Percussion is not typically used to assess heart abnormalities or rebound tenderness.

Question 18

A 75-year-old patient is breathing at a rate of 30 and denies dyspnea. The breath sounds are clear to auscultation in all five lobes. The nurse will further assess the patient's respiratory and circulatory systems by checking capillary refill. A normal finding would be

Accepted Answer

A normal capillary refill time is less than 3 seconds, but in older adults it can range up to 5 seconds. Pink nail beds indicate adequate circulation, so the combination of pink nail beds and a capillary refill time of 5 seconds is a normal finding for an older adult patient. Nail beds that are cyanotic or blanched may indicate poor circulation.

Question 19

After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the patient's plan of care. This decision is a result of the nurse's

Accepted Answer

The nurse determining that no changes are needed in the patient's plan of care after completing the initial head-to-toe shift assessment indicates that the nurse has evaluated the effectiveness of the nursing interventions already implemented. This is a key component of the nursing process and helps determine if the current plan of care is appropriate or if adjustments need to be made. The other options are not directly related to this situation.

Question 20

The nurse takes additional time getting to know a patient admitted for surgery because

Accepted Answer

Establishing rapport with a patient leads to a trusting nurse-patient relationship, which can improve patient outcomes and satisfaction with care. Additionally, getting to know the patient can help the nurse identify any unique needs or concerns that may affect their care during and after surgery.

Quiz 21: Physical Assessment