NUR216 Health Assessment Exam 4 - Arizona College of Nursing
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Free NUR216 Health Assessment Exam 4 - Arizona College of Nursing Questions
The nurse is auscultating a client's heart sounds and hears a murmur at the second intercostal space, right of the sternum. Which area is the nurse listening to?
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Pulmonic area
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Mitral area
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Aortic area
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Tricuspid area
Explanation
Correct Answer: (C) Aortic area The aortic area is located at the second intercostal space, right of the sternum, making it the correct auscultation site for this finding.
Why the other options are incorrect:
A. The pulmonic area is located at the second intercostal space on the left side of the sternum, not the right.
B. The mitral area is located at the fifth intercostal space at the midclavicular line, not the upper sternal border.
D. The tricuspid area is located at the fourth or fifth intercostal space at the left lower sternal border, not the upper right sternum.
The nurse cares for a client undergoing an MRI and states, "I can't stand this - I have to get out of here!" What should the nurse do first?
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Reschedule the magnetic imaging
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Medicate the client with lorazepam
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Ask the client to take several deep breaths
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Contact the health care provider
Explanation
Correct Answer Is:
(C) Ask the client to take several deep breaths.
The client is showing signs of claustrophobia or acute anxiety during the MRI. The nurse's first action should be a simple, immediate, non-pharmacologic intervention such as deep breathing to help calm the client before considering other measures.
Why the other options are incorrect:
A. Rescheduling the procedure is premature and does not address the client's immediate distress; a simple calming intervention should be attempted first.
B. Medicating with lorazepam requires a provider's order and is not the first-line intervention for acute situational anxiety that may be resolved with simpler measures.
D. Contacting the health care provider is not necessary as a first step; the nurse can independently intervene with calming techniques before escalating care.
The nurse is conducting a lymphatic system assessment. Which finding should the nurse document as abnormal?
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Lymph nodes that are firm, non-mobile, and tender.
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Lymph nodes that are small, soft, and non-tender.
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Lymph nodes that are enlarged but soft and freely movable.
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Lymph nodes that are round, mobile, and non-tender.
Explanation
Correct Answer: (A) Lymph nodes that are firm, non-mobile, and tender. Firm, non-mobile (fixed), and tender lymph nodes are abnormal findings that may indicate infection, inflammation, or malignancy, requiring further evaluation and documentation as a concerning finding.
Why Other Options are Incorrect:
B. Small, soft, non-tender lymph nodes are a normal, expected finding.
C. Enlarged but soft and freely movable lymph nodes are typically associated with a benign reactive process, such as a mild infection, rather than a highly concerning finding.
D. Round, mobile, non-tender lymph nodes are a normal, expected finding.
While assessing the spine of a client, the nurse notes an increased inward curvature of the lumbar spine and an arched lower back appearance. Which deformity should be suspected?
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Scoliosis
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Ankylosis
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Kyphosis
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Lordosis
Explanation
Correct Answer Is:
D
Lordosis is characterized by an exaggerated inward curvature of the lumbar spine, producing an arched, "swayback" appearance of the lower back, which matches the findings described.
Why the other options are incorrect:
A. Scoliosis is an abnormal lateral (sideways) curvature of the spine, not an inward lumbar curve.
B. Ankylosis refers to stiffening and fixation of a joint due to fusion, not a curvature deformity.
C. Kyphosis is an excessive outward/forward curvature of the thoracic spine, producing a hunched appearance, which is the opposite of the lumbar findings described.
After a client is diagnosed with a chronic illness, the nurse is evaluating the client's stress response. Which observation indicates the need for additional assessment?
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The client seeks information about the condition and treatment options.
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The client uses journaling to express and process feelings.
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The client isolates themselves and refuses to discuss their diagnosis with others.
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The client engages in regular physical activity as a form of stress relief.
Explanation
Correct Answer: (D) "I will limit my fluid during the day." This statement requires further teaching because limiting fluid intake is inappropriate and can lead to concentrated urine, which irritates the bladder and can actually worsen urgency symptoms; clients should instead be encouraged to maintain adequate, well-timed fluid intake.
Why the other options are incorrect:
A. Establishing a toileting schedule is correct teaching, as scheduled voiding helps manage urge incontinence by proactively emptying the bladder before urgency occurs.
B. Restricting caffeine is correct teaching, as caffeine is a bladder irritant and diuretic that can worsen urgency and incontinence symptoms.
C. Taking diuretics in the morning is correct teaching, as this timing helps reduce nighttime urinary urgency and incontinence episodes.
The nurse is performing a neurological assessment on a client and is assessing the client's ability to distinguish between sharp and dull sensations. Which part of the body should the nurse assess for this test?
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Skin
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Muscles
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Ears
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Eyes
Explanation
Correct Answer Is:
A
Sharp and dull sensation discrimination is a test of peripheral sensory nerve function, performed by lightly touching the skin with sharp and dull objects to assess the client's ability to differentiate between the two sensations.
Why the other options are incorrect:
B. Muscles are tested for strength and tone, not sharp/dull sensory discrimination.
C. Ears are assessed for hearing function, not tactile sensation.
D. Eyes are assessed for vision and pupillary response, not sharp/dull touch sensation.
The nurse is conducting a head-to-toe assessment on a client. Which of the following should the nurse assess first?
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Respiratory system
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Cardiovascular system
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General Survey
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Neurological system
Explanation
Correct Answer Is:
C
The general survey is always performed first in a head-to-toe assessment, as it provides an overall initial impression of the client's appearance, behavior, and obvious distress before proceeding to system-specific assessments.
Why the other options are incorrect:
A. The respiratory system assessment occurs after the general survey has established a baseline overall impression.
B. The cardiovascular system is assessed after the general survey, not as the first step.
D. The neurological system, like other body systems, is assessed following the initial general survey.
A client reports leg pain that wakes them at night and describes a "sore" on the inner aspect of the right ankle. On assessment, the nurse notices loss of hair on the lower right leg, and a small, black area on the right ankle. What should the nurse expect from these findings?
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Pain related to musculoskeletal abnormalities.
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Problems related to arterial insufficiency.
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Problems related to venous insufficiency.
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Pain related to lymphatic abnormalities.
Explanation
Correct Answer:
B
Why the other options are incorrect:
A. Musculoskeletal pain would not explain the hair loss and black necrotic wound findings, which point to a vascular cause.
C. Venous insufficiency typically presents with pain that improves with elevation, edema, and ulcers with irregular borders on the medial ankle, along with brown discoloration rather than the black necrotic tissue and hair loss described.
D. Lymphatic abnormalities typically cause swelling (lymphedema) rather than hair loss and black necrotic skin changes.
The nurse performs a cardiovascular assessment on a 66-year-old client. Which finding should the nurse note as unexpected?
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Heart rate 62 beats per minute
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S1 and S2 heard at all five landmarks
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Jugular vein distention
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Peripheral pulses +2 and regular
Explanation
Correct Answer: (C) Jugular vein distention Jugular vein distention is an abnormal finding that indicates increased central venous pressure, often associated with right-sided heart failure or fluid volume overload, and requires further evaluation.
Why the other options are incorrect:
A. A heart rate of 62 beats per minute is within the normal adult range of 60–100 bpm.
B. Hearing S1 and S2 at all five cardiac landmarks is a normal, expected finding during cardiovascular auscultation.
D. Peripheral pulses rated +2 and regular are within the normal expected range on the pulse amplitude scale.
The nurse is assessing a client with asthma. Which finding may be a sign of acute respiratory distress?
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Respiratory rate of 18 breaths per minute while resting.
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Difficulty talking between breaths with tachypnea.
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Clubbing of the fingernails.
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Barrel shaped chest.
Explanation
Correct Answer: (B) Difficulty talking between breaths with tachypnea. Difficulty speaking in full sentences combined with tachypnea (rapid breathing) indicates the client is working hard to breathe, signaling acute respiratory distress requiring immediate attention.
Why the other options are incorrect:
A. A respiratory rate of 18 breaths per minute while resting is within the normal adult range and is not a sign of distress.
C. Clubbing of the fingernails is a sign of chronic hypoxia over time, not an indicator of acute respiratory distress.
D. A barrel-shaped chest is associated with chronic conditions like COPD due to long-term air trapping, not an acute distress indicator.
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