NURSING NUR 3065 Assessment A . Graded A

NURSING NUR 3065 Assessment A Set A 1. The nurse is percussing the 7th right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear: A) Dullness B) Tympanic C) ...

NURSING NUR 3065 Assessment A Set A 1. The nurse is percussing the 7th right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear: A) Dullness B) Tympanic C) Resonance D) Hyperresonance 2. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid Colon 3. A patient is having difficulty in swallowing medication and food. The nurse would document that this patient has: A) Aphasia B) Dysphasia C) Dysphagia D) Anorexia 4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region B) Inspect and palpate in the epigastric region C) Auscultate and percuss in the inguinal region D) Percuss and palpate the midline area above the suprapubic bone 5. The nurse is aware that one change that may occur in the GI system of an aging adult is: A) Increase salivation B) Increase liver size C) Increase esophageal emptying D) Decreases gastric acid secretion 6. A 22 y.o. man comes to the clinic for an examination after falling off his motorcycle and landing of his left side on the handlebars. The nurse suspects that he may injure his spleen. Which of this statement is true regarding assessment of the spleen in this situation? A) The spleen can be enlarged as a result of trauma B) The spleen is normally felt upon routine palpation C) If an enlarge spleen is noticed, the nurse should palpate thoroughly to determine size D) An enlarged spleen should not be palpated because it can rupture easily 7. A patient abdomen is bogging and strange in appearance. The nurse should describe this finding as: A) Obese B) Herniated C) Scaphoid D) Protuberant 8. The nurse is describing scaphoid abdomen. To the horizontal plane, scaphoid contour of the abdomen depicts a _________________ profile. A) Flat B) Convex C) Bulging D) Concave 9. While examining a patient, the nurse observes abdominal pulsation between the xiphoid and the umbilicus. The nurse would suspect that these are: A) Pulsation of the renal arteries B) Pulsations of the inferior vena cava C) Pulsations of the abdominal aortic D) Increased peristalsis from a bowel obstruction 10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) Diarrhea B) Peritonitis C) Laxatives use D) Gastroenteritis 11. The nurse is watching a new graduate nurse performed auscultation of a patient abdomen. Which statement by the new graduated shows a correct understanding of the recent auscultation precedes percussion and palpation of the abdomen? A) We need to determine areas of tenderness before using percussion and palpation B) If prevent distortion of bowel sounds that might occur after percussion and palpation C) Allows the patient more time to relax and therefore be more comfortable with the physical examination D) This prevents distortion of vascular sound such as bruits and hums that might occur after percussion and palpation 12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? A) They are usually loud, high-pitched, rushing, tinkling sounds. B) They are usually high-pitched, gurgling, irregular sounds. C) They sound like two pieces of leather being rubbed together. D) They originate from the movement of air and fluid through the large intestine. 13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) A loud continuous hum B) A peritoneal friction rub C) Hypoactive bowel sounds 14. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpate spleen between the ninth and eleventh ribs in the left mid axillary line D) A dull percussion note in the left upper quadrant at the mid clavicular line. 15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: A) Diarrhea. B) Pyrosis. C) Dysphagia. D) Constipation. 16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: A) Flatness, resonance, and dullness. B) Resonance, dullness, and tympany. C) Tympany, hyperresonance, and dullness. D) Resonance, hyperresonance, and flatness. 17. In performing an assessment of a woman’s axillary lymph system, the nurse should assess which of these nodes? A) Central, axillary, lateral, and sternal B) Pectoral, lateral, anterior, and sternal C) Central, lateral, pectoral, and subscapular D) Lateral, pectoral, axillary, and suprascapular 18. A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? A) She can expect her areolae to become larger and darker in color. B) Breasts may begin secreting milk after the fourth month of pregnancy. C) She should inspect her breasts for visible veins and immediately report these. D) During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth. 19. The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? A) 37 year old who is slightly overweight B) 42 year old who has had ovarian cancer C) 45 year old who has never been pregnant D) 65 year old whose mother had breast cancer 20. The nurse is palpating a female patient’s breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? A) Supine with the arms raised over her head B) Sitting with the arms relaxed at her sides C) Supine with the arms relaxed at her sides D) Sitting with the arms flexed and fingertips touching her shoulders 21. The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct? A) “BSE is more important than ever for you because you have never had any children.” B) “BSE is so important because one out of nine women will develop breast cancer in her lifetime.” C) “BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations.” D) “BSE will save your life because you are likely to find a cancerous lump between mammograms.” 22. During an examination, the nurse notes a supernumerary nipple just under the patient’s left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? A) This variation is normal and not a significant finding. B) This finding is significant and needs further investigation. C) A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. D) The patient is correct—a supernumerary nipple is actually a mole that happens to be located under the breast. 23. While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: A) dimpling B) retraction C) Peau d’orange. D) Benign breast disease. 24. The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? A) Nontender mass B) Dull heavy, pain on palpation C) Robbery texture and movable D) Hard, dense, and immobile E) Irregular, poorly delineated border F) Regular borders 25. The external male genital structures include the: A) Testis B) Scrotum C) Epididymis D) Vas Deferens 26. An accessory glandular structure for the male genital organs is the: A) Testis B) Scrotum C) Prostate D) Vas deferens 27. Which statement concerning the testes is true? A) The lymphatic vessels of the testes drain into the abdominal lymph nodes. B) The vas deferens is located along the inferior portion of each testis. C) The right testis is lower than the left because the right spermatic cord is longer. D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body. 28. A 62-year-old man states that his physician told him that he has an “inguinal hernia.” He asks the nurse to explain what a hernia is. The nurse should: A) Tell him not to worry and that most men his age develop hernias. B) Explain that a hernia is often the result of prenatal growth abnormalities. C) Refer him to his physician for additional consultation because the physician made the initial diagnosis. D) Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles. 29. A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: A) dysuria B) nocturia C) polyuria D) hematuria 30. When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is: A) Called hypospadias. B) A result of phimosis. C) Probably due to a stricture. D) Often associated with aging. 31. When performing a genital assessment on a middle-aged man, the nurse notices multiple, soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristics of: A) Carcinoma. B) Syphilitic chancres. C) Genital herpes. D) Genital warts. 32. During a physical examination, the nurse finds that a male patient’s foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is: A) phimosis B) epispadias C) urethral stricture D) peyronie disease 33. A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died of prostate cancer. The nurse knows which tests should be performed at this time? A) blood test for prostate specific antigen B) urinalysis C) Transrectal ultrasound D) digital rectal examination E) prostate biopsy 34. During an examination, the nurse would expect the cervical os of a woman who has never had children to appear: A) Stellate. B) Small and round. C) As a horizontal irregular slit. D) Everted. 35. The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass’s characteristics would suggest the presence of an ovarian cyst? answers all correct: A) Heavy and solid B) Mobile and fluctuant C) Mobile and solid D) Fixed E) Smooth and round F) Poorly defined 36. For purposes of examination and communication of physical findings, the breast is divided into: A) Halves upper and lower B) Thirds (left, middle, and right) C) 4 quadrants plus Tale D) Circles (6 consecutives rings, each 1 inch further away from nipples) 37. A peppering of nontender, nonsuppurative Montgomery tubercles is considered to be a: A) normal finding B) sign of carcinoma C) skin disease D) symptom of malnutrition 38. The tail of Spence extends: A) into the midclavicular region B) toward the supraclavicular area C) down into the inframammary ridge D) into the axillae 39. The assessment of which structure is not part of the bimanual examination: A) Cervix B) Bladder C) Uterus D) Ovaries 40. When palpating the abdomen, you should know whether the liver is enlarged in the: A) left lower quadrant B) mid-epigastric region C) periumbilical area D) right upper quadrant 41. Costovertebral angle tenderness should be assessed whenever you suspect that the patient may have: A) Colecystitis B) Pancreatitis C) Pyelonephritis D) Ulcerative colitis