Assessment--EAQ 15--Wk 8

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Which rationale explains why a patient with congenital heart disease develops clubbing?

It is a disorder of the nail.

It is caused by insufficient oxygenation at the periphery. (correct)

It is a condition that runs in families.

It is secondary to neurological damage caused by heart disease.

Which pulse is difficult to palpate in a normal patient?

Femoral pulse

Brachial pulse

Popliteal pulse (correct)

Dorsalis pedis pulse

Which factor is considered a risk factor for heart disease? ---SATA---

Smoking (correct)

Lack of exercise (correct)

Alcohol ingestion (correct)

A low-cholesterol diet

Which position is the most suitable for an abdominal examination?

Dorsal recumbent position Signup and view all the answers

According to the American Cancer society guidelines, how often should a 52-year-old patient undergo a colonoscopy?

Every 10 years Signup and view all the answers

What would the nurse palpate for the apical impulse?

At the fourth intercostal space just medial to the left midclavicular line Signup and view all the answers

In addition to cyanotic lips and nail beds, nasal faring and pursed lips, which sign would directly indicate that a patient is suffering from cardiac or pulmonary insufficiency?

Clubbing of the fingers Signup and view all the answers

While auscultating the bowel sounds in a patient, the nurse reports borborygmi. Which characteristic sound is present?

Hyperactive sound Signup and view all the answers

During a vascular system assessment, the nurse hears a blowing sound in the carotid artery of the patient. Which finding would the nurse include in the medical report?

Bruit Signup and view all the answers

Which statement made by the nursing student indicates the need for further teaching regarding examination of the abdomen?

"I will ask the patient to place the arms under the head." Signup and view all the answers

For which reason would the nurse ask the patient about a history of hemodialysis?

To identify a risk factor for the hepatitis B virus Signup and view all the answers

How would the nurse examine the organs in the abdomen to evaluate abdominal pain?

Palpate the abdomen by applying deep pressure with one or both hands. Signup and view all the answers

Which statement represents accurate patient teaching regarding frequency of screening tests for colorectal cancer?

"A double contrast barium enema is recommended every 5 years." Signup and view all the answers

In which position are the rectum and anus of a non ambulatory patient examined?

Lateral recumbent position Signup and view all the answers

Which information would the nurse include when teaching a patient with poor arterial circulation about checking blood flow in the legs?

A normal pulse on the top of the foot indicates adequate blood flow to the foot. Signup and view all the answers

A patient with a history of chronic inflammatory bowel disease reports to the health care provider about the presence of black, tarry-colored stools. On further assessment, the health care provider prescribes a radiographic examination of the colon and rectum. Which other patient finding would support the prescription for a radiographic exam?

Obesity Signup and view all the answers

Which nursing intervention would be beneficial for a patient who has pancreatitis?

Observing the patient's movements and positions. Signup and view all the answers

While assessing the bowel motility of a patient, the nurse finds an absence of sounds. Which condition might be the reason? ---SATA---

Peritonitis Signup and view all the answers

Which action made by the nursing student requires further teaching regarding assessment of venous pressure?

Asking the patient to be in the high-Fowler's position Signup and view all the answers

Which factor led the nurse to suspect alterations in the upper gastrointestinal tract?

Bloody emesis Signup and view all the answers

Which statement if made by the nursing student indicates a need for further teaching regarding assessment of the lymphatic system?

"I should gently palpate the inguinal node, located on the medial aspect of the arms." Signup and view all the answers

Which point is important for the nurse to include when teaching students about abdominal assessment?

The aorta can be felt using deep palpation in the upper abdomen near the midline. Signup and view all the answers

The nurse who is conducting cardiac assessment of a patient notices a very loud thrill that is easily palpable. Which grade would be assigned to this thrill? Grade ___

5 Signup and view all the answers

Which statement made by the nursing student indicates the need for further teaching regarding abdominal assessments?

"I will assess for painful areas when starting the assessment." Signup and view all the answers

Which nursing intervention is appropriate when performing an abdominal examination and the patient's abdominal muscles have tightened?

Asking the patient to move the arms from under the head. Signup and view all the answers

Which action by the nurse might have caused an older adult to develop syncope during assessment of the carotid arteries?

Palpating the carotid arteries vigorously. Signup and view all the answers

Which statement regarding the assessment of the jugular veins is true?

They should be inspected first to measure the venous pressure. Signup and view all the answers

Which statement regarding the assessment of the peripheral veins is true?

Pitting edema can be assessed by pressing the index finger firmly for several seconds over the medial malleolus or the shins. Signup and view all the answers

Which statement made by the nursing student indicates the need for further teaching regarding phlebitis?

"I should assess for Homans' signs." Signup and view all the answers

The nurse is measuring a patient's pulse by directing the patient to lie down. Then the nurse places the fingertips of both hands on the opposite sides of the pulse site. Which puts is the nurse measuring?

Femoral pulse Signup and view all the answers