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Adult Health Assessment Final Exam
Professional Nursing I (NUR 3805)
Florida International University
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Adult Health Assessment Final Exam
1- Best position to auscultate high and low pitch heart murmurs?
The nurse is assessing a client who has a low-pitched murmur. What is the most appropriate way for the nurse to position the client to auscultate this murmur? A) Supine using the bell of the stethoscope B) Supine using the diaphragm of the stethoscope C) On the left lateral side using the bell of the stethoscope D) On the left lateral side using the diaphragm of the stethoscope
● In auscultating a client's heart sounds, a nurse hears a swooshing sound over the precordium. The nurse recognizes this sound as which of the following? Murmur
2- Which electrolyte increase blood pressure?
When performing a dietary history on a client with a cardiovascular history, the nurse should obtain information related to which items? A) Dairy consumption B) Sodium intake C) Whole grain intake D) Vitamin supplements
3- Best position when performing a cardiovascular assessment? Cardiac auscultation should be conducted with the patient in three positions. These are sitting up, lying on the left side, and lying on the back with the head of the bed raised 30 to 45 degrees. Murmurs and pericardial friction rubs are best heard with the patient sitting up and leaning forward.
In preparing to preform a cardiovascular assessment, the nurse should initially place the client in which position? A) Supine B) Lithotomy C) Sitting upright D) Prone
Before assessing the client's carotid arteries for pulsations, the nurse would raise the client's head of bed to how many degrees elevation for proper positioning? 45 degree angle.
4- How do you examine the carotid arteries, proper assessment and things to avoid?
The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique? A) Auscultating all heart sounds with the bell and diaphragm. B) Inspecting bilateral jugular veins. C) Palpation of the point of maximum impulse on the chest. D) Palpating carotid pulses simultaneously.
When palpating the carotid arteries it is essential that the nurse do which of the following? A) Palpate the carotids while the patient is supine B) Avoid palpating the carotids simultaneously C) Determine if there is a heave D) Palpate for an enlarged heart
5- Approach used to perform a cardiovascular assessment on a school age.
What approach would the nurse use to elicit the cooperation of a School-age child during a cardiovascular assessment? A) Explain the procedure to the child B) Explain the procedure to the parents C) Permit the child to listen to his or her parent’s chest with stethoscope D) Sedate the child
6- What do we use the bell of the stethoscope? And how is related to murmurs, which type of murmur specifically? Diastolic murmur or mitral stenosis
The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, you should listen with the diaphragm, and repeat with the bell). The bell is more sensitive to the low-pitched sounds of S3(extra beat of the heart, congestive feilure, completed normal in pregnant) and S4 and the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal with its full rim. Use the bell at the apex, and then move medially along the lower sternal border. Resting the heel of your hand on the chest like a fulcrum may help you to maintain light pressure.
Possible Questions
The client has a history of aortic stenosis and an S3 murmur. What action would the nurse take to auscultate this murmur? A) Listen at the pulmonic area
A) Presence of fever B) Description of the pain and location C) Recent weight gain D) Whether the client smokes
9- Symptoms of CAD (objective symptoms specifically?) CAD - coronary artery disease
CAD—Assessment Objective: -Vital signs -Assessment of lungs, heart and abdomen -EKG -Oxygen saturation -SOB -S3 (third heart sound) -Pale, cool, clammy skin, sweats -Diminished pulses
- creases
The nurse is performing a cardiovascular assessment and notes creases in the client’s earlobes. Based on this finding the nurse would conclude that the client may be experiencing which condition? A) Endocarditis B) Pericarditis C) Coronary artery disease D) Fluid overload
10- What's the meaning of bounding pulses? Related to fever
Recommended Grading of Pulses 3+ Bounding 2+ Brisk, expected (normal) 1+ Diminished, weaker than expected 0 Absent, unable to palpate
Bounding pulse : is a pulse with an increased volume that feels very strong and full. A bounding pulse may indicate decreased elasticity of the arterial walls, most commonly seen with aging. Bounding pulse occurs when there is a huge difference between diastolic and systolic pressures - you can get it with vasodilation, anemias, hypercarbia.
During inspection of the carotid arteries the nurse assesses a bounding pulse. The nurse should evaluate the client for which additional finding? A) Fever B) Bruits C) Chest pain D) Cyanosis
11- Pulmonary edema symptoms
Pulmonary edema is a complication of various heart and lung diseases and usually occurs from increased pulmonary vascular pressure secondary to severe cardiac dysfunction.
- restlessness, anxiousness... changes in LOC = d/t hypoxia
- sudden shortness of breath, paroxysmal nocturnal dyspnea (fine all day, but to do bed and lay flat, get increased venous return from legs, and it can be more fluid than left ventricle can handle)
- crackles
- pale > cyanosis
- gurgling respirations - secretions
- pink frothy sputum
- ABG - lower o2, increased co
- tachycardia - may lead to arrhythmias
The nurse is performing a cardiovascular assessment. To evaluate the client for pulmonary edema the nurse would assess the client for which manifestation? A) Edema in the lower extremities B) Shortness of breath C) A thrill D) Splinter hemorrhages
12- If you have HTN, which side of the heart can you palpate for pulsation (which cardiac landmark?) ● The nurse assessing a client who has a history of hypertension would assess the client for pulsations by palpating which cardiac landmark? A) Fifth intercostal space, midclavicular line B) Second intercostal space, right sternal border C) Pulmonic area D) Tricuspid area
13- How do you examine Facial Nerve?
A) 3
2) 6
3) 10
4) 15
16- How to check for orientation vs level of consciousness - Orientation: ask question about person, place and time - Consciousness: Glascow Coma Scale
17- CN3 examination techniques Check six cardinal positions of gaze: ask patient to follow your finger
18- What’s is the Romberg test for and how do you do it? Also use for driving under the influence THE ROMBERG TEST. This is mainly a test of position sense. The patient should first stand with feet together and eyes open and then close both eyes for 30 to 60 seconds without support. The nurse should stand next to the patient without touching him or her, in case of loss of balance, with arms in front and back of the patient. Note the patient’s ability to maintain an upright posture. Normally only minimal swaying occurs.
What does a positive Romberg's test indicate? That visual input was compensating for a balance problem. This suggests sensory or vestibular ataxia
19- What is orthostatic hypotension, diplopia, vertigo and bradycardia Orthostatic hypotension is a drop in systolic blood pressure of at least 20 mm Hg or in diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing. Assess the patient for orthostatic hypotension, defined as a drop in SBP of 20 mm Hg or more or DBP of 10 mm Hg or more within 3 minutes of standing. Measure blood pressure and HR in two positions: supine after the patient rests for up to 10 minutes, sitting and then within 3 minutes after standing up. Check the patient in 3 position Symptoms include lightheadedness, weakness, unsteadiness, visual blurring, and, in 20% to 30% of patients, syncope. Causes include medications, autonomic disorders, diabetes, prolonged bed rest, volume depletion, amyloidosis, postprandial state, and cardiovascular disorders.
Diplopia : Diplopia (double vision) is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either eye is closed. A range of conditions can cause double vision, including problems within the eye, such as the cornea or lens. Other underlying causes can involve muscles or nerves controlling eye function and movement, or issues in the brain.
Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve CN III or VI, or vertical diplopia from palsy of CN III or IV. Diplopia in one eye, with the other closed, suggests a problem in the cornea or lens.
Vertigo refers to the perception that the patient or the environment is rotating or spinning. These sensations point primarily to a problem in the labyrinths of the inner ear, peripheral lesions of cranial nerve CN VIII, or lesions in its central pathways or nuclei in the brain.
Bradycardia is a slower than normal heart rate. The hearts of adults at rest usually beat between 60 and 100 times a minute. If you have bradycardia, your heart beats fewer than 60 times a minute. Causes for bradycardia include: Problems with the sinoatrial (SA) node, sometimes called the heart's natural pacemaker. Problems in the conduction pathways of the heart that don't allow electrical impulses to pass properly from the atria to the ventricles. Metabolic problems such as hypothyroidism (low thyroid hormone)
Possible Questions An older adult is admitted to the medical surgical unit for dehydration. The nurse performs which of the assessments to determine whether the client is safe for independent ambulation? A. Assessed for dry oral mucus membranes B. Evaluate the serum potassium level is 4 mEq (4 mmol/L) C. Notes pulse rate is 72 bpm and bounding D. Checks for orthostatic blood pressure changes
A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?
A. Normal B. Bradycardia C. Tachycardia D. Decreased
20- Anosmia what is and how do you check for it. Anosmia, also known as smell blindness, is the loss of the ability to detect one or more smells. Anosmia may be temporary or permanent. It differs from hyposmia, which is a decreased sensitivity to some or all smells. CN I disfunction, patient to close eyes and then smell coffee, closing one nostrum at a time
Hyperresonance
22- Fremitus what is and how do you do it - It is for vibratory tremors that can be felt through chest palpation. - The way to do it is by asking the patient to say “99” or “bluemoon”, palpate the chest from one side to the other while the patient is speaking.
During a respiratory assessment, the nurse would elicit fremitus by doing which of the following during the examination? A) Placing the hands over anterior and posterior lung fields, asking the client to say “99” B) Asking the client to say “99” while listening to the lungs with a stethoscope C) Palpating the anterior and posterior chest and costal margins D) Percussing over the anterior and posterior chest
Which finding does the nurse expect when performing tactile fremitus? A) A vibration of sounds that are equal bilaterally b) A change in muscle tone when the patient inhales and exhales, indicating weakness c) The symmetric rise of the thorax as the patient speaks, indicating equal expansion d) Coughing triggered by patient speech, indicating bronchial irritation
23- Correct sequence of examining the lungs
The pulmonary examination consists of inspection, palpation, percussion, and auscultation.
A student is practicing the performance of a lung examination on a classmate. Which of the following is the correct order for performing the components of the lung examination? a) Auscultation, inspection, palpation, and percussion b) Palpation, inspection, auscultation, and percussion c) Auscultation, percussion, palpation, and inspection d) Inspection, auscultation, percussion, and palpation e) Auscultation, inspection, palpation, and percussion f) Inspection, palpation, percussion, and auscultation when examine the lungs first anterior part first and then the posterior part in that sequence (f)
24- What's a normal Respiratory Rate for all ages, child, middle age, pregnant woman and older adult with lung disease. Respiratory Rate assessment 98 1 to 3 years - 24-40 RR (breaths/minute) 3 to 6 years - 22-34 RR 6 to 12 years - 18-30 RR 12-18 years - 12-16 RR
Adults - 12-20 RR Older adult with lung disease - tachypnea (> 20 breaths/min) Pregnant woman: The patient has 24 RR who would be? Or RR of 25, 18 RR for a child, 20 a middle age or adult
5 MSK y 5 Gastroinstestinal
Adult Health Assessment Final Exam
Course: Professional Nursing I (NUR 3805)
University: Florida International University
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