head/neck/lymphatics
During a head and neck lymph node assessment, which technique should the nurse use?
Palpate with the pads of the middle three fingers using a gentle rotary motion
During inspection of an adult patient's thorax, which finding should the nurse recognize as an expected normal finding?
Anteroposterior diameter one-third to one-half of the transverse diameter
where are the apices of the lungs located
inner 1/3 of clavicle, 3-4 inches above clavicle
Which heart sound corresponds to the closure of the tricuspid and mitral valves?
The nurse uses the angle of Louis to landmark the cardiac auscultation sites. Which anatomical structure is located at the level of the angle of Louis?
The second rib
Which position best promotes relaxation when the nurse palpates the cervical lymph nodes?
Have the patient sit with the neck slightly flexed forward
The nurse is assessing tactile fremitus in a patient with suspected lobar pneumonia. Which finding is most consistent with increased lung tissue density?
Increased tactile fremitus over the affected lobe
the area where the trachea bifurcates
sternal angle
Where should the nurse expect S1 to be loudest during cardiac auscultation?
The nurse is landmarking the tricuspid and mitral areas before auscultation. what are the correct locations?
Tricuspid area at the fifth left intercostal space close to the sternum
Mitral area at the fifth intercostal space on the left midclavicular line
The nurse is beginning a systematic assessment of the head and neck lymph nodes. Which sequence is appropriate?
Preauricular, posterior auricular, occipital, tonsillar, submandibular, and submental
Which action should the nurse take when auscultating the posterior thorax?
Ask the patient to fold the arms in front of the chest and bend the head forward
vesicular
Where is the point of maximum impulse found?
5th ICS MCL
During cardiac auscultation, the nurse follows a systematic pattern beginning at this anatomical site.
aortic valve -- 2nd ICS R sternal border
Which finding during lymph node palpation requires further investigation because it may indicate disease?
A hard, fixed cervical node
While percussing the chest, which finding should the nurse expect over normal lung tissue?
Resonance over the lung fields
During auscultation, the nurse hears short, low-pitched sounds caused by air passing through airways intermittently occluded by mucus. Which sound is being assessed?
Crackles
the difference between the apical pulse and radial pulse is called?
pulse deficit
This part of the stethoscope should be used to auscultate for low-pitched extra heart sounds such as S3 and S4.
The bell placed gently
Which technique should the nurse use to palpate the supraclavicular lymph nodes?
Ask the patient to bend the head forward and relax the shoulders, then hook the fingers over the clavicle lateral to the sternocleidomastoid
During palpation, the nurse notes that the patient's trachea is displaced away from the affected side. Which condition is associated with this finding?
Tension pneumothorax
The musical sound noted in the lungs on inspiration and/or expiration...especially in patients with asthma
wheezes
The nurse is preparing to auscultate the heart and needs to locate the aortic area first. Where should the stethoscope be placed?
Second intercostal space at the right sternal border
The nurse is assessing a patient's lower-leg edema. Which technique should the nurse use to assess for pitting edema?
Press firmly over the medial malleolus or shin for several seconds, then release