Part 5 Health Assessment

7/27/2019 Part 5 Health Assessment

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1Marks: 0/1

Nurse Jade is about to assess peripheral nerve motor function. She will check for the motor

function of the median nerve by:

Choose one answer.

a. Asking the client to abduct all fingers

b. Asking the client to oppose thumb andsmall finger and asking the client to flex his

wrist

If the nurse wants to check the motorfunction of the median nerve, she shouldask the client to oppose his thumb and smallfinger and she should also note whether theclient can flex his wrist. Motor function of theradial nerve is assessed by asking the clientto hyperextend his thumb then wrist and tohyperextend the four fingers at the MCP

joints. For the ulnar nerve, the client shouldbe asked to abduct all fingers. The peronialnerve is checked by asking the client todorsiflex the ankle and to extend the toes atthe metatarsal phalangeal joints. The tibialnerve is assessed by asking the client toplantar flex the ankle and toes. (Black andHawks, 2005)

c. Asking the client to hyperextend his

thumb then wrist

d. Asking the client to dorsiflex his ankle and

extend toes at the metatarsal phalangealjoints

Incorrect

Marks for this submission: 0/1.

Question2Marks: 0/1

You are assessing the neck vessels of your client who has shown signs and symptoms of

cardiovascular disease. You auscultate his carotid artery and you hear a blowing, swishing

sound. This is called:

Choose one answer.

a. Bruit A bruit is a blowing, swishing soundindicating blood flow turbulence due to alocal vascular cause. A murmur is blowing,swooshing sound that occurs with turbulentblood flow in the heart or great vessels. S3 orventricular gallop occurs with heart failure


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and volume overload. (Jarvis, 2004)

b. S3

c. None of the choices

d.Murmur

Incorrect


Question3Marks: 0/1

In palpating the clients carotid pulses, the nurse should not observe which of the following

measures?

Choose one answer.

a. Palpating the pulses one at a time

b. Palpating the pulses simultaneously inorder to determine if there is equal blood flow

on both sides

The nurse should not palpate the carotidpulses simultaneously since this may obstructblood flow to the brain. When palpating thecarotid pulses, the nurse should ask the clientto look straight ahead and to keep the neckstraight. The pulses should be palpatedseparately. If the pulse is difficult to palpate,the client should be asked to turn his headslightly to the examining side. (Damico and

Barbarito, 2007)

c. Having the client turn his head slightly tothe examining side if the pulse is difficult to

palpate

d. Asking the client to look straight ahead and

to keep the neck straight.

Incorrect


Question4

Marks: 0/1

From thejugular veins, the nurse can assess the central venous pressure and judge the hearts

efficiency as a pump. When estimating the jugular venous pressure, the nurse should use the

following anatomical landmark:

Choose one answer.


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a. Trapezius muscle

b. 2nd intercostal space

c. Angle of Louis The CVP can be read at the highest

level of jugular pulsations. The angle ofLouis (sternal angle) is the arbitraryreference point. A ruler should be heldvertically on the sternal angle. Astraight edge should be aligned on theruler like a T-square, and the horizontalstraight edge should be adjusted to thelevel of the pulsation. The level of theintersection should be read on the ruler.Normal jugular venous pulsation is 2cm or less above the sternal angle.(Jarvis, 2004)

d.Suprasternal notch

Incorrect


Question5Marks: 0/1

You are checking for shifting dullness in your client who is suspected to have ascites. You turn

your client towards you and start to percuss his abdomen from the upper side moving downward.

If the client has fluid in his abdomen, you would expect the following finding:

Choose one answer.

a. The sound changes from tympany to

dull as you percuss downward

Shifting dullness is another test for ascites.In a supine person, ascitic fluid settles bygravity into the flanks, displacing the air-filledbowel upward. You will hear a tympaniticnote as you percuss over the top of theabdomen. Then percuss down the side ofthe abdomen. If fluid is present, the note willchange from tympany to dull as you reach itslevel. The client should then be turnedtowards you. The fluid will gravitate to thedependent side. Begin percussing the upper

side of the abdomen and move downward.The sound changes from tympany to a dullsound as you reach the fluid level. (Jarvis,2004)

b. The sound changes from dull to

resonant as you percuss downward


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c. The sound changes from dull to

tympany as you percuss downward

d. The sound changes from resonant to

dull as you percuss downward

Incorrect


Question6Marks: 0/1

Allens test is performed in order to:

Choose one answer.

a. Determine the patency of the radial and

ulnar arteries

Allens test is done to determine t hepatency of the radial and ulnar arteries.Manual compression test is done to

determine the length of a varicose vein andthe competency of its valves. Testing forHomans sign is done in order to check ifthere is a blood clot In one of the deep veinsof the leg. (Damico and Barbarito, 2007)

b. All of the choices

c. Determine the competency of the valves of

a varicose vein

d. Determine if there is a blood clot in one of

the deep veins of the leg

Incorrect


Question7Marks: 0/1

Bowel sounds originate from the movement of air and fluid through the small intestine. How

long must you listen to the clients bowel sounds before you decide that they are completely

absent?

Choose one answer.

a. 3 minutes

b. 10 minutes

c. 5 minutes It is uncommon for the abdomen to be perfectlysilent. Before deciding that the bowel sounds arecompletely silent, the nurse must auscultate the


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abdomen for 5 minutes. (Jarvis, 2004)

d. 1 full minute

Incorrect


Question8Marks: 0/1

For adolescent clients, this is an essential part of musculoskeletal assessment:

Choose one answer.

a. LaSegues test

b. Testing for Trendelenburgs sign

c. Ortolanis maneuver

d. Forward bend test For adolescents, special attention should begiven to assessment of spinal posture.Screening for scoliosis should be performedthrough the forward bend test. Ortolanismaneuver is done on infants to check forcongenital dislocation. Testing forTrendelenburgs sign is done on children toscreen progressive subluxation of the hip.LaSegues test is done to confirm thepresence of a herniated nucleus pulposus (the

jelly-like substance in the middle of the spinaldiscs). (Jarvis, 2004)

Incorrect


Question9Marks: 0/1

Physical assessment of the cardiovascular system requires the use of inspection, palpation,

percussion and auscultation. When auscultating the clients chest to check for murmurs, which

part of the stethoscope should you use?

Choose one answer.

a. Use the diaphragm to check the apical area and

the bell for the other areas

b. Bell The clients chest should beauscultated using the bell of thestethoscope. Low-pitched sounds are


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best heard with light application of thebell. Sounds such as S3, S4, murmursand gallops are best auscultated withthe bell, as well. (Damico andBarbarito, 2007)

c. Either the bell or the diaphragm

d. Diaphragm

Incorrect


Question10Marks: 0/1

A pulse deficit is checked by:

Choose one answer.

a. Palpating the PMI while simultaneously

palpating the radial pulse

b. Subtracting the diastolic blood pressure

from the systolic blood pressure


d. Auscultating the apical beat while

simultaneously palpating the radial pulse

A pulse deficit is checked by auscultating theapical beat while simultaneously palpating theradial pulse. Subtracting the diastolic blood

pressure from the systolic blood pressureproduces the pulse pressure. (Jarvis, 2004)

Incorrect



Which of the following organs cannot be appreciated through deep palpation of the abdomen?

Choose one answer.

a.Spleen Normally, the spleen is not palpable and must beenlarged three times its normal size to be felt. It isnormal to feel the edge of the liver bump yourfingertips as the diaphragm pushes it down duringinhalation. Occasionally, you may feel the lower poleof the right kidney when the client takes a deepbreath. The left kidney sits 1 cm higher than theright kidney and is not palpable normally. The aortic


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pulsation can be palpated in the upper abdomenslightly to the left of midline. (Jarvis, 2004)

b.Liver

c.Aorta

d.Right kidney

Incorrect



Neurovascular assessment of the musculoskeletal system includes checking the peripheral

nerves. The nurse assesses the radial nerve when she:

Choose one answer.

a. Pricks the web space between the

thumb and the index finger

To assess sensation in the area traversed bythe radial nerve, the nurse should prick theweb space between the thumb and theforefinger. For the ulnar nerve, the nurseshould prick the distal fat pad of the smallfinger. For the median nerve, the nurseshould prick the distal surface of the indexfinger. For the peronial nerve, the nurseshould prick the web space between thegreat toe and second toe. For the tibial nerve,the nurse should prick medial and lateral

surfaces of the sole of the foot. (Black andHawks, 2005)

b. Pricks the distal surface of the index

finger

c. Pricks the medial and lateral surfaces

of the sole of the foot

d. Pricks the web space between the

great toe and the second toe

Incorrect



The nurse can differentiate ascites from gaseous distention by performing two percussion tests,

one of which is the fluid wave test. In performing this test you should not:

Choose one answer.


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a. Give the clients flank a firm tap using onehand while keeping your other hand against

the clients other flank

b. Place the ulnar edge of the clients hand

firmly on the abdomen in the midlinec. None of the choices

d. Perform indirect fist percussion over the

costovertebral angle on the back

The answer is perform indirect fist percussionover the costovertebral angle. This is done inorder to assess the kidneys. In testing for afluid wave, the nurse should stand on theclients right side. The ulnar edge of anotherexaminers hand or the patients own handshould be placed firmly on the abdomen inthe midline. The nurse should place her lefthand on the clients right flank and with her

left hand she should give the left flank a firmstrike. If ascites is present, the blow willgenerate a fluid wave through the abdomenand the nurse would feel a distinct tap on herleft hand. (Jarvis, 2004)

Incorrect



As you are performing assessment of your clients extremities, you notice the presence of edema

on your clients legs. You press his skin and take note of 4 mm depression. Using the edemagrading scale, this should be recorded as?

Choose one answer.

a. 2+ Edema should be graded on a scale of 1+ (mild) to 4+(severe) depending on the depth of the indentationmade by the finger on the clients skin.2 mm = 1+4 mm = 2+6 mm = 3+8 mm = 4+(Damico and Barbarito, 2007)

b. 1+

c. 3+

d. 4+

Incorrect


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The nurse is about to check her clients capillary refill. She should remember that the following

conditions can skew her findings, except:

Choose one answer.

a.Peripheral edema

b. A cool room

c. Increased body temperature Capillary refill is an index of peripheral perfusionand cardiac output. Usually, the vessels refill in lessthan 1 or 2 seconds. Refill lasting more than 1 or 2seconds signifies vasoconstriction or decreased

cardiac output. Conditions that may skew thenurses findings are: a cool room; DECREASEDbody temperature; cigarette smoking; peripheraledema. (Jarvis, 2004)

d. Cigarette smoking

Incorrect



The following is correct about assessment of the joints, except:

Choose one answer.

a. Passive motion should be attempted if you

see a limitation in joint motion

b. None of the choices

c. Joint motion normally causes no tenderness,

pain or crepitation

d. The synovial membrane is normally doughy orboggy upon palpation

The synovial membrane is normally notpalpable. When thickened, it feelsdoughy or boggy. Joints are normallynot tender to palpation and joint motionnormally does not cause any pain orcrepitation. If the nurse sees a limitationin joint movement, she should gentlyattempt passive motion. (Jarvis, 2004)


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Incorrect



Prior to performing physical examination of the abdomen, appropriate actions of the nurseinclude the following, except:

Choose one answer.

a.Encouraging the client to drink 500 cc of

water

The answer is encouraging the client todrink 500 cc of water. Prior to abdominalexamination, the client should beencouraged to void. A warm andcomfortable environment should beprovided and the client should beinstructed regarding what is expected ofhim during the procedure (e.g. taking deepbreaths to relax abdominal muscles).Drapes should be provided to preventunnecessary exposure of the client.(Damico and Barbarito, 2007)

b. Providing instructions about what is expected

of the client

c. Providing a warm environment

d. Providing drapes

IncorrectMarks for this submission: 0/1.


13. The apical impulse (formerly called the point of maximal impulse) should be assessed by the

examiner. Normally, where can the apical impulse be palpated?

Choose one answer.

a. 5th ICS, left midclavicular line The apical pulse should occupy only oneinterspace, the fourth or fifth, and be at or

medial to the left midclavicular line. (Jarvis,2004)

b. 4th ICS, right midclavicular line

c. 3rd ICS, left anterior axillary line

d. 2nd ICS, right sternal border


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Incorrect



You note that your client has positive Tinels sign. Which of the following cues supports thisfinding?

Choose one answer.

a. There was burning and tingling along thedistribution of the median nerve when the

median nerve is percussed

There is positive Tinels sign if there is aburning and tingling along thedistribution of the median nerve whenthe location of the median nerve at thewrist is percussed. Phalens test iselicited by asking the client to hold bothhands back to back while flexing thewrists 90 degrees. Both of these testsare done to determine if the client hascarpal tunnel syndrome. (Jarvis, 2004)

b. None of the choices

c. There is carpal tunnel syndrome

d. There was numbness and burning when theclient was asked to hold both hands back to back

while flexing the wrists 90 degrees

Incorrect



Assessment of peripheral vessels includes testing for Homans sign. This is done through:

Choose one answer.

a. Plantar flexing the clients foot while he is

sitting on the bed

b. Sharply dorsiflexing the clients foot while he is

lying supine

To test for Homans sign, the client

should be assisted to a supine position.His knee should be flexed about 5degrees, then his foot should be sharplydorsiflexed. There is positive Homanssign if calf pain becomes present upondorsiflexion of the foot. (Damico andBarbarito, 2007)


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c. Plantar flexing the clients foot while he is lying

on the bed

d. Dorsiflexing the clients foot while he is sitting

on the bed

Incorrect



Abdominal palpation is performed in order to judge the size, location and consistency of certain

organs and to screen for an abnormal mass or tenderness. When you encounter an area of

tenderness upon palpation, your most appropriate action would be to:

Choose one answer.

a. Save examination of the tender area for

last

The examination of any identified tender

areas should be saved until last in order toavoid pain and the resulting muscle rigiditythat would obscure palpation later in theexamination. (Jarvis, 2004)

b. Continue palpating the area, while asking the

client about the characteristics of the pain


d. Stop palpating the abdomen and inform the

physician about your findings



The room should be warm when you are assessing the clients heart for this reason:

Choose one answer.

a. Cold temperature makes the blood

more viscous

b. Cold temperature slows down the

heart

c. Shivering interferes with heart

sounds

The room must be warm because chilling makesthe client uncomfortable, and shivering interfereswith heart sounds. (Jarvis, 2004)

d. Cold temperature makes the


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stethoscope less sensitive to sound

Incorrect



The obturator test is one of the tests performed when appendicitis is suspected. Which of the

following is the proper procedure in performing the obturator test?

Choose one answer.

a. Holding the fingers under the liver to border

and asking the client to take a deep breath

b. None of the choice

c. Lifting the right leg, flexing at the hip and 90degrees at the knee; then holding the ankleand rotating the leg internally and

externally

The obturator test is done with the clientlying supine. The nurse should lift the rightleg, flexing at the hip and 90 degrees atthe knee. She should then hold the ankleand rotate the leg internally and externally.The iliopsoas muscle test is also donewhen appendicitis is suspected. This isdone by assisting the client to a supineposition then lifting the right leg straight up,flexing at the hip; then pushing down overthe lower part of the right thigh as theclient tries to hold the leg up. Testing forinspiratory arrest or Murphys sign is done

by holding the fingers under the liverborder and asking the client to take a deepbreath. (Jarvis, 2004)

d. Assisting the client to a supine position thenlifting the right leg straight up, flexing at thehip; then pushing down over the lower part of

the right thigh

Incorrect



As you are inspecting your very thin clients abdomen, you take note of the following findings.

Which of them is abnormal?

Choose one answer.

a.Displaced umbilicus A displaced umbilicus could indicate anabdominal mass or distended urinary


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bladder. In very thin clients, a scaphoidabdomen is normal. It is also normal toobserve a pulsation of the abdominalaorta below the xiphoid process in thinclients. The abdominal skin should beconsistent in color and luster with the

rest of the body. The skin should besmooth, moist and free of lesions.(Damico and Barbarito, 2007)

b.Scaphoid contour

c.Pulsation below the xiphoid process

d.Smooth skin

Incorrect



As you are assessing the range of motion of the clients cervical spine, you would ask the client

to perform all of the following except:

Choose one answer.

a.Attempting to touch each shoulder with the

ear on that side

b. Looking up towards the ceiling

c. Moving his head in a circular motion The client should not be asked to move hishead in a circular motion. In order to test theROM of the cervical spine, the nurse shouldinstruct the client to flex the neck bytouching the chest with his chin; tohyperextend by looking up towards theceiling; to flex laterally by attempting totouch each shoulder with the ear on thatside; and to rotate the neck by turning thehead to face each shoulder as far aspossible. (Damico and Barbarito, 2007)

d. Touching the chest with his chin

Incorrect




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Nurse Mila is assessing Mr. Procopios neck vessels. Among nurse Milas actions, which of the

following is inappropriate?

Choose one answer.

a. Inspecting carotid artery pulsations

unilaterally

Inspecting carotid artery pulsations

unilaterally is Nurse Milas inappropriateaction. With the client lying still at a 45-degree angle, carotid arteries should beinspected bilaterally for pulsations. On theother hand, jugular vein distention shouldbe measured only on one side. Tangentiallighting is effective in visualizing the jugularvessels. (Damico and Barbarito, 2007)

b. Having the client lie at a 45-degree angle

when inspecting the carotid arteries

c. Using tangential lighting to examine jugular

vessels

d. Measuring jugular vein distention only on

one side of the neck

Incorrect



In assessing an elderly clients musculoskeletal function, you keep in mind the age-related

changes of the musculoskeletal system. Structural changes include all but one of the following

Choose one answer.

a.Progressive loss of bone mass

b.Deterioration of cartilage

c. Increased risk for fractures Age-related structural changes of themusculoskeletal system include: gradual,progressive loss of bone mass >35 years ofage; increase in collagen and resultant fibrosis;muscle atrophy and wasting; decreasing

elasticity of tendons; progressive deteriorationof cartilage; thinning of intravertebral discs; laxligaments. Functional changes include:increased risk for fractures; loss of strength andflexibility; stiffness, reduced flexibility and paininterfering with ADLs; and postural jointabnormalities. (Smeltzer, et al, 10th ed)


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d. Muscles decrease in size

Incorrect



Assessing muscle strength is part of the nurses responsibilities. In order to do this, a numerical

rating system is used. Giving a muscle strength rating of 4 means that the particular muscle

group:

Choose one answer.

a. Has full ROM against normal resistance and

gravity

b. Has full ROM against moderate resistance Muscle strength should be rated

numerically as follows:0 = muscle is paralyzed with no visibleor palpable contraction1 = contraction is palpable but muscledoes not move2 = full ROM is present with the jointsupported to eliminate gravity3 = full ROM is present with gravity asthe only resistance4 = full ROM is present againstmoderate resistance5 = full ROM is present against normalresistance and gravity

(Black and Hawks, 2005)

c. Is paralyzed with no visible or palpable

contraction

d. Has full ROM when the joint is supported to

eliminate gravity

Incorrect



In assessing peripheral pulses, the following characteristics should be noted, except:

Choose one answer.

a. None of the choices The answer is none of the choices. In assessingperipheral pulses, the following characteristicsshould be noted: rate (the number of beats perminute); rhythm (the regularity of the beats);


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symmetry (pulses on both sides of the bodyshould be similar); amplitude (the strength of thebeat. (Damico and Barbarito, 2007)

b. All of the choices

c.Rhythm

d.Symmetry

e.Amplitude

Incorrect



Nurse Minda checks her clients fingers to detect clubbing. She recalls that the normal nail bedangle is:

Choose one answer.

a. 190 degrees

b. 160 degrees The normal nail bed angle is 160 degrees.Flattening of the angle and clubbing occur withcongenital cyanotic heart disease, cor pulmonaleand subacute bacterial endocarditis. (Jarvis, 2004)

c. 120 degrees

d. 180 degrees

Incorrect



The focused interview for the cardiovascular system concerns data related to the structures and

functions of that system. Which of the following wouldnt you ask the client when you are trying

to obtain subjective data about his cardiac status?

Choose one answer.

a. Have you experienced a change in your

weight?

b. Do you know your cholesterol and

triglyceride levels?


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c. All of the choices

d. None of the choices The answer is none of the choices. It isimportant to ask the client if there is anyonein his family who has a cardiovasculardisease because this may reveal information

about cardiovascular ailments associatedwith familial disposition. Weight gain orweight loss may accompany systemicdiseases such as diabetes, which increasesthe risk for cardiovascular illnesses.Moreover, obesity and high percentage ofbody fat; and elevated cholesterol andtriglyceride levels are risk factors forcardiovascular disease. (Damico andBarbarito, 2007)

e. Is there anyone in your family who has

had a cardiovascular disease?Incorrect



It is difficult to isolate the aging process of the cardiovascular system because it is so closelyinterrelated with lifestyle, habits and diseases. Which of the following changes would you expect

upon assessment of the cardiovascular status of an elderly client?

Choose one answer.

a. A slight increase in the overall size

of the heart

b. An increase in diastolic blood

pressure

c. A decrease in resting heart rate

d. An increase in systolic blood

pressure

From age 20 to 60, systolic blood pressuretends to increase by about 20 mmHg, and byanother 20 mmHg between ages 60 and 80.This is due to the stiffening of large arterieswhich is due to calcification of vessel walls. Theoverall size of the heart does not increase withage but the left ventricular wall thickens. Nosignificant change in diastolic pressure occurswith age, and there is also no change in restingheart rate. (Jarvis, 2004)

Incorrect



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Which of the following tests is not used to detect fluid in the suprapatellar bursa?

Choose one answer.

a. None of the choices

b. Testing for the bulge sign

c.McMurrays test McMurrays test is performed for a clientwho has reported a history of traumafollowed by locking, giving way or localpain in the knee. Both testing for the bulgesign and ballottement confirm the presenceof fluid in the suprapatellar pouch. (Jarvis,2004)

d.Ballottement

Incorrect



Physical assessment of the abdomen requires the use of the four basic techniques in the

following order:

Choose one answer.

a. Inspection, percussion, palpation,

auscultation

b. Inspection, palpation, percussion,

auscultation

c. Inspection, auscultation, palpation,

percussion

d. Inspection, auscultation, percussion,

palpation

Abdominal assessment techniques followthis sequence, inspection- auscultation-

percussion- palpation. Delayingpercussion and palpation preventsdisturbance of the normal bowel sounds.(Damico and Barbarito, 2007)

Incorrect


Question35


20/23

Marks: 0/1

Which of the following should the nurse remember when checking for rebound tenderness?

Choose one answer.

a. She should push down directly over the

painful area

b. She should push down quickly and

deeply then lift up slowly

c. She should choose a site away from the

painful area

Rebound tenderness should be assessed whenthe client reports abdominal pain or when thenurse elicits tenderness during palpation. Thenurse should choose a site away from thepainful area. The hand should be heldperpendicular to the abdomen and she shouldpush down slowly and deeply; then lift up

quickly. This makes structures that areindented by palpation rebound suddenly. Thistest should be performed at the end of theexamination because it can cause severe painand muscle rigidity. (Jarvis, 2004)

d. She should perform it at the beginning

of the examination

Incorrect



The nurse has to listen to the four traditional valve areas. Where should the nurse auscultate

when listening for pulmonic valve sounds?

Choose one answer.

a. 5th interspace, left midclavicular line

b. 2nd left interspace The valve areas are not over the actualanatomic locations of the valves, but are thesites on the chest wall where the sounds

produced by the valves are best heard. Aorticvalve sounds are best heard over the 2nd rightinterspace; PULMONIC VALVE sounds are bestheard over the 2nd LEFT INTERSPACE;tricuspid valve sounds are heard over the leftlower sternal border; mitral valve sounds arebest heard over the 5th interspace at around leftmidclavicular line. (Jarvis, 2004)


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c. 2nd right interspace

d. Left lower sternal border

Incorrect



As you are auscultating the clients heart sounds, you keep in mind that S1 is the start of systole

and thus serves as the reference point for the timing of all other cardiac sounds. Which of the

following is true about the characteristics that distinguish S1 from S2?

Choose one answer.

a. S2 coincides with the carotid artery

pulse

b. S1 is louder than S2 at the apex S1 is the first in a pair of sounds heard uponauscultation of the heart; this guideline works exceptin the cases of tachyarrhythmias where the beats aretoo close together to distinguish. S1 is louder than S2at the apex; S2 is louder than S1 at the base. S1coincides with the carotid artery pulse. (Jarvis, 2004)

c. The intensities of S1 and S2 are

equal over all auscultatory areas

d. S1 is louder than S2 at the base



The nurse is performing cardiovascular assessment on her client. Which of the following could

be found through the use of palpation?

Choose one answer.

a.Thrills Thrills are soft vibratory sensations best

assessed with either the fingertips or the palmflattened over the chest. Heaves or lifts areforceful risings of the landmark area, and they areassessed through inspection. A bruit is a loudblowing sound assessed through auscultation.(Damico and Barbarito, 2007)

b.Heaves


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c.Bruits

d. Lifts

Incorrect



You are assessing Mrs. Villas cardiovascular status. Which of the following findings would not

alert you of a condition that may compromise the function of the clients cardiovascular system?

Choose one answer.

a. Visible jugular veins when the client is

sitting upright

b. Periorbital puffiness

c. None of the choices Protruding eyes are seen in hyperthyroidism. Inthis condition, excessive hormone secretion resultsin high cardiac output, a tendency towardtachycardia, and potential for congestive heartfailure. Periorbital puffiness may result from fluidretention (edema) or valvular disease. Jugularveins are not normally visible when the client sitsupright. (Damico and Barbarito, 2007)

d. Protruding eyes



Percussion of the abdomen is done to assess the relative density of abdominal contents, to locate

organs, and to screen for abnormal fluid or masses. Which of the following sounds should

predominate when the nurse is percussing the clients abdomen?

Choose one answer.

a. Flat

b. Dull

c.Tympanitic Percussion over the abdomen producestympany. Dullness is heard over the liverand spleen. A resonant sound is normallyheard over the lungs and a flat sound is


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normally heard over bony areas.(Damico and Barbarito, 2007)

d.Resonant

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Part 5 Health Assessment