NUR 209 Midpoint Assessment

Correct Answer: Prevention places emphasis on the link between health and personal behavior.

Explanation:

Prevention in health care focuses on reducing the risk of disease and promoting health by addressing personal behaviors and lifestyle choices. Many preventable diseases are directly linked to behaviors such as smoking, poor diet, lack of exercise, and alcohol use. By addressing these behaviors, individuals can reduce their risk for chronic diseases and improve overall health. Prevention also involves educating individuals on making healthier choices to reduce their risk of illness and improve quality of life.

Why the other options are incorrect:

Disease can be prevented by treating the external environment. While environmental factors can contribute to health risks, prevention is not solely focused on the external environment. Personal behaviors and lifestyle choices are a major focus, as they are often more directly manageable by individuals. Environmental factors are only part of the broader prevention strategy.

The majority of deaths among Americans under age 65 years are not preventable. This statement is inaccurate. Many of the leading causes of death in individuals under 65 (such as heart disease, diabetes, and certain cancers) are preventable or manageable through changes in behavior, lifestyle, and early detection. Prevention strategies can significantly reduce the risk of these diseases.

The means to prevention is through treatment provided by primary health care. While primary health care is essential for managing health and providing preventive services (such as vaccinations, screenings, and health education), prevention goes beyond treatment alone. It includes promoting healthy lifestyle choices and reducing risk factors that contribute to disease. Prevention also involves public health efforts and individual actions to reduce risk factors before illness occurs.

Summary:

The correct answer is C. Prevention emphasizes the link between health and personal behavior, recognizing that lifestyle choices play a significant role in preventing many diseases. While environmental factors and primary health care are important, personal behavior and prevention efforts targeted at reducing risk factors are key components of a health-focused prevention strategy.

The correct answer is:

Respiratory depression

Decreased sensation in the lower extremities

Slurred speech

Explanation:

The nurse must be vigilant for complications when caring for a client with an epidural in place during labor. While some effects like decreased sensation are expected, others may indicate more serious problems that need immediate attention. Below is the explanation for each answer:

Respiratory depression:

Respiratory depression is a serious and potentially life-threatening side effect of epidural anesthesia, especially if opioids are used as part of the epidural regimen. It can cause a significant reduction in the client's ability to breathe effectively, which may lead to insufficient oxygenation. Immediate reporting to the anesthesiologist is necessary so the anesthesiologist can adjust the medication and monitor the client closely. This is the most critical finding that requires immediate attention.

Decreased sensation in the lower extremities:

Decreased sensation in the lower extremities is expected and normal with an epidural, as the goal is to block pain sensation in the lower half of the body. The nurse should ensure that the sensation loss is symmetrical and not associated with any motor deficits. If there is asymmetry or the client loses motor control (e.g., difficulty moving the legs), this could indicate a complication such as an epidural hematoma or a problem with the placement of the catheter. Therefore, decreased sensation should be reported if it is abnormal or there are additional signs of motor impairment.

Slurred speech:

Slurred speech is a concerning symptom that may indicate a central nervous system effect from the epidural medication, such as local anesthetic toxicity or opioid overdose. It may also suggest neurological impairment. This requires immediate reporting to the anesthesiologist for further evaluation to ensure that the client is not experiencing a serious complication related to the epidural anesthesia.

Why the other choices are incorrect:

Blood pressure 108/62:

This blood pressure reading is within the normal range for a pregnant client in labor, especially after receiving an epidural. A drop in blood pressure is a common side effect of epidural anesthesia due to vasodilation, but a reading of 108/62 is not alarmingly low. As long as the client is not showing signs of hypoperfusion (e.g., dizziness, fainting), this does not need immediate reporting to the anesthesiologist. This blood pressure is acceptable in most cases.

Sustained fetal heart rate of 150 bpm:

A fetal heart rate of 150 beats per minute is within the normal range for a fetus (110–160 bpm). While the fetal heart rate should be monitored for signs of fetal distress, a sustained heart rate of 150 bpm does not indicate any immediate concern or require intervention. The nurse should continue to monitor fetal well-being but does not need to report this to the anesthesiologist immediately.

Summary:

The nurse should immediately report respiratory depression (A) and slurred speech (E) to the anesthesiologist, as they may indicate severe complications related to the epidural anesthesia that need urgent intervention. Decreased sensation in the lower extremities (C) should also be reported if it is uneven or associated with motor deficits, as it could signal a problem with the epidural. Blood pressure 108/62 (B) and sustained fetal heart rate of 150 bpm (D) are within normal limits and do not require immediate reporting.

The correct answer is: Extend 3 to 4 cm above the inner third of the clavicles

Explanation:

The apices of the lungs are the topmost portions of the lungs and extend upward into the thoracic cavity. They are located approximately 3 to 4 cm above the inner third of the clavicles. This anatomical feature is important to know when assessing lung sounds and understanding the location of lung pathology, as the uppermost regions of the lungs can sometimes be involved in respiratory conditions such as tuberculosis or lung cancer.

Why the Other Choices Are Incorrect:

Are at the level of the second rib anteriorly

This is incorrect. The apices of the lungs are not located at the level of the second rib anteriorly. The lungs generally extend down to around the level of the sixth rib anteriorly, while the apices are higher up, closer to the clavicles.

Are located at the sixth rib anteriorly and the eighth rib laterally

This is incorrect. The apices of the lungs are much higher than the sixth rib anteriorly. The lung bases generally reach the level of the sixth rib in the midclavicular line, but the apices are located higher up near the clavicles, as described in option B.

Rest on the diaphragm at the fifth intercostal space in the midclavicular line

This is incorrect. The diaphragm does not reach the fifth intercostal space in the midclavicular line; rather, the diaphragm typically rests around the sixth rib in the midclavicular line. The apices are located above this, much higher in the thoracic cavity.

Summary:

The correct answer is B, "Extend 3 to 4 cm above the inner third of the clavicles," as this is the true location of the apices of the lungs. The other options either describe the lung bases or incorrect anatomical landmarks.

The correct answer is: Increased density of lung tissue

Explanation:

A dull percussion note over a lung lobe typically indicates an area of increased tissue density. This can be due to a variety of factors, such as consolidation (as seen in pneumonia), a tumor, or a pleural effusion (fluid buildup in the pleural space). The increased density of the lung tissue reflects a shift from the normal resonant sound of healthy lung tissue to a duller sound, which is associated with more solid or fluid-filled structures.

Why the Other Choices Are Incorrect:

Shallow breathing

Shallow breathing would not typically produce a dull percussion note. In fact, shallow breathing can result in decreased air movement, but it would not directly affect the density of the lung tissue enough to cause dullness on percussion. A dull note is more associated with abnormal lung tissue changes.

Normal lung tissue

Normal lung tissue typically produces a resonant percussion note because it is filled with air, which transmits sound waves more effectively. A dull percussion note suggests something other than normal lung tissue, such as consolidation or fluid accumulation.

Decreased adipose tissue

Decreased adipose tissue would not directly cause a dull percussion note over the lung. While increased fat can affect the transmission of sound, it is unlikely to create the density changes associated with a dull percussion note. The primary cause of dullness is a change in the tissue density of the lungs, not the amount of fat surrounding them.

Summary:

The correct answer is D, "Increased density of lung tissue," because a dull percussion note is most commonly caused by conditions that increase the density of lung tissue, such as consolidation, tumors, or pleural effusions. The other options are less likely to cause dullness and typically do not reflect the density changes observed in abnormal lung conditions.

The correct answer is: A systolic murmur

Explanation:

A murmur is an abnormal sound caused by turbulent blood flow. The timing of the murmur in the cardiac cycle is important for proper documentation. When turbulence is heard between the S1 and S2 heart sounds, this indicates a systolic murmur, as the S1 marks the beginning of systole (ventricular contraction) and S2 marks the end of systole (ventricular relaxation). A systolic murmur occurs during the phase when the ventricles are contracting, and it can be caused by factors like valve stenosis, regurgitation, or turbulent blood flow through the heart.

Why the Other Choices Are Incorrect:

A third heart sound (S3)

A third heart sound (S3) occurs just after S2, during early diastole, and is associated with rapid ventricular filling. It is heard as a low-pitched sound, not turbulence between S1 and S2, so it would not be described in this context.

An expected heart sound

An expected heart sound would not involve turbulence or an abnormal sound like a murmur. Normal heart sounds are S1 and S2, and they do not typically involve any extra sounds or turbulence in between.

A fourth heart sound (S4)

A fourth heart sound (S4) occurs just before S1, during atrial contraction, and is associated with stiff or non-compliant ventricles. It is not heard between S1 and S2, so it would not be the correct answer in this case.

Summary:

The correct answer is A, "A systolic murmur," because the turbulence between S1 and S2 is characteristic of a systolic murmur. The other options describe different heart sounds or normal findings, none of which fit the description of the sound heard between S1 and S2.

The correct answer is: 5 minutes.

Explanation:

In an abdominal assessment, the nurse should listen for bowel sounds for at least 5 minutes before determining that they are absent. If bowel sounds are not heard after this extended period, it may be considered a sign of ileus or intestinal obstruction, which requires further evaluation.

Why the Other Choices Are Incorrect:

1 minute.

Listening for only 1 minute is not enough time to adequately assess bowel sounds. Bowel sounds may be intermittent, and 1 minute may not be sufficient to detect any sounds.

10 minutes.

Listening for 10 minutes is excessive for this purpose. Five minutes is generally considered the standard duration to rule out the absence of bowel sounds.

 2 minutes in each quadrant.

While listening to each quadrant is essential, it is the total duration of 5 minutes that is required, not 2 minutes in each quadrant.

Summary:

Before reporting "absent bowel sounds," the nurse should listen for at least 5 minutes to ensure that the sounds are indeed absent, allowing for an accurate assessment.

The correct answer is: A graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members.

Explanation:

A genogram is a graphic representation of a family tree that provides more detailed information about family relationships, including gender, age, and health history. It visually organizes information about family members to identify patterns or hereditary health risks. The use of symbols allows the nurse to quickly assess and document family history, which is essential for understanding genetic risks and the patient's health.

Why the other options are incorrect:

A list of diseases present in a person's near relatives.

While a genogram can include health information, it is not just a list of diseases. A genogram is more comprehensive and visually depicts family relationships and health conditions across generations, not just a simple list.

A drawing that depicts the patient's family members up to five generations back.

This description is partially correct, but not entirely accurate. While a genogram can depict multiple generations, it is typically more focused on the immediate family and health history that may influence the patient's current health. It doesn't always extend to five generations.

A description of the health of a person's children and grandchildren.

This is incorrect because a genogram is a visual diagram of family relationships, not a detailed health description of specific relatives. It may include health information, but it is not limited to children and grandchildren and focuses on a broader family history.

Summary:

The correct answer is B because a genogram is a graphic family tree that uses symbols to depict gender, relationships, and age of immediate family members. It is more than a simple list of diseases or a health description of specific relatives. It is a valuable tool for assessing family health patterns and risks.

The correct answer is: They are usually high-pitched, gurgling, irregular sounds.

Explanation:

Bowel sounds are typically high-pitched, gurgling, and irregular sounds that result from the movement of air and fluid through the intestines. These sounds vary in frequency and intensity, depending on the location and function of the intestines. Normal bowel sounds can be heard intermittently throughout the abdomen.

Why the Other Choices Are Incorrect:

They are usually loud, high-pitched, rushing, tinkling sounds.

While bowel sounds can be high-pitched, loud, rushing, tinkling sounds are often indicative of gastrointestinal obstruction or increased bowel motility, not normal bowel sounds.

They sound like two pieces of leather being rubbed together.

This description is characteristic of pericardial friction rubs or pleural friction rubs, not bowel sounds. This type of sound is typically associated with inflammation in the pericardium or pleura.

They originate from the movement of air and fluid through the large intestine.

While bowel sounds do occur in the large intestine, they originate from the movement of air and fluid through the small intestine and large intestine, not just the large intestine. Both parts contribute to the sounds.

Summary:

Normal bowel sounds are high-pitched, gurgling, and irregular in nature (B), resulting from the movement of air and fluid through the intestines. These sounds should be heard at regular intervals and vary depending on the activity in the gastrointestinal tract. 

The correct answer is: A tympanic percussion note in the umbilical region.

Explanation:

The umbilical region of the abdomen typically produces a tympanic percussion note due to the presence of air in the intestines. This is considered a normal finding as the bowel is filled with air, which gives a tympanic (drum-like) sound when percussed.

Why the Other Choices Are Incorrect:

The presence of a bruit in the femoral area.

A bruit is an abnormal sound, often indicative of turbulent blood flow due to narrowed arteries or vascular abnormalities. The presence of a bruit in the femoral area could suggest a vascular issue and should be further investigated. It is not considered normal.

A palpable spleen between the ninth and eleventh ribs in the left midaxillary line.

A palpable spleen is not a normal finding in most adults. The spleen is usually not palpable unless it is enlarged due to conditions like splenomegaly. A palpable spleen should be investigated further to determine the underlying cause.

A dull percussion note in the left upper quadrant at the midclavicular line.

A dull percussion note in the left upper quadrant is typically associated with the stomach or spleen, but it can also indicate abnormal findings such as splenomegaly or other pathologies. It is not automatically considered normal unless related to structures like the stomach, where a dull sound may be heard.

Summary:

A tympanic percussion note in the umbilical region (B) is normal, as it is due to the air-filled bowel. The other findings suggest potential abnormalities that would need further investigation.