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Flashcards in weekly quiz qestions Deck (229)
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How should the nurse document mild, slight non-pitting edema present at the ankles of a pregnant patient?

1+ on a 0-4+ scale


A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has?



The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse?

A) Bounding
B) Normal
C) Weak
D) Absent

B) Normal

Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.


The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:

examine the tender area last


Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which statements is correct?

It should fall off by 10-14 days


The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

hyperactive bowel sounds


The nurse is performing a peripheral vascular assessment on a bedridden patient and notices the following findings in the right leg: increased warmth, swelling, tenderness, tenderness to palpation, and a positive Homan's sign. The nurse should:

seek emergency referral because of the risk of pulmonary embolism


The nurse notices that the patient has had a black, tarry stool and recalls that a possible cause would be:

gastrointestinal bleeding


A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

A) diarrhea.
B) peritonitis.
C) laxative use.
D) gastroenteritis.

B) peritonitis.

Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.


A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:



When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:

bruits occur with turbulent blood flow, indicating partial occlusion.


During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:

A) 1 minute.
B) 5 minutes.
C) 10 minutes.
D) 2 minutes in each quadrant.

B) 5 minutes.

Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.


During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:

Raynaud's disease/phenomenom


A nurse notices that a patient has ascites, which indicates the presence of:
A) fluid.
B) feces.
C) flatus.
D) fibroid tumors.

A) fluid

Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.


A patients has a positive Homen's sign. The nurse knows that a positive Homen's sign may indicate:

deep vein thrombosis


A 67-year old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:



The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
A) "We need to determine areas of tenderness before using percussion and palpation."
B) "It prevents distortion of bowel sounds that might occur after percussion and palpation."
C) "It allows the patient more time to relax and therefore be more comfortable with the physical examination."
D) "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."

B) "It prevents distortion of bowel sounds that might occur after percussion and palpation."

Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.


During an abdominal assessment, the nurse elicits tenderness on light palpation in the lower right quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?



The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?
A) Woman in her second month of pregnancy
B) Person who has been on bed rest for 4 days
C) Person with a 30-year, 1 pack per day smoking history
D) Elderly person taking anticoagulant medication

B) person who has been on bed rest for 4 days

At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.


During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with non-pitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?



During an assessment of a 26 year old at the clinic for a "spot on my lip I think is cancer" the nurse notices a group of clear vesicles with an erythematous base around them located at the lip/skin border. The patient mentions that she just returned form Hawaii. What would be the most appropriate response from the nurse?

Tell the patient it is most likely herpes simplex 1 and will heal in 4 to 10 days.


A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has?

Bell's Palsy


A 19 yr old college student is brought tho the ED with a severe headache he describes as "like nothing I have ever had before" Hie temp 104 F and he has a stiff neck. The nurse looks for other signs and symptoms of what?



During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects what?

A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial pressure

B. dehydration

Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.


A patient's lab data reveal an elevated thyroxine level. The nurse would proceed to examine what gland?



The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?

A) Tachycardia
B) Constipation
C) Rapid dyspnea
D) Atrophied nodular thyroid

A) Tachycardia

Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.


Nurse is palpating sinus areas. If they are normal the patient will report what sensation?

firm pressure


Patient presents with excruciating headache on one side of head, around his eye, forehead and cheek. They last 1/2 - 2 hours and happen once or twice a day. The nurse suspects what?

cluster headaches


A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of:

A) cachexia.
B) Parkinson's syndrome.
C) myxedema.
D) scleroderma.

C) myxedema.

Pages: 276-277. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.


A male patient with a history of AIDS has come in for an examination and states, "I think that I have the mumps." The nurse would begin by examing what?

parotid gland