Respiratory
The correct method for auscultating breath sounds is to:
compare areas from side to side
Name 2 physical functions of the cerebellum, and 2 intellectual functions of the cerebellum.
Voluntary movement, posture, balance, equilibrium
Thoughts, emotions, social behavior
Name the three abnormal heart sounds you could hear.
List 3 abnormal observations of abdominal appearance
dilated veins, cyanosis, ascites, jaundice
When auscultating lung sounds the nurse would expect to hear which of the following sounds directly over the trachea?
sounds that are harsh and loud
movement, temperature, speech, judgement, thinking/reasoning, problem-solving, emotions, learning
Which intercostal space is the apex located?
5th ICD, midclavicular line
Differentiate between hypoactive and active bowel sounds
hypoactive - long intervals of silence between gurgles
Active - can be heart anywhere from 5-34 times a minute.
You hear occasional popping sounds during auscultation of your patient. Which of the following nursing interventions could you perform which may make these sounds disappear?
ask the patient to cough or change position
An expected finding of the Romberg Test is
minimal swaying for at least 5 seconds
List three causes of edema
Congestive Heart Failure, renal failure, pregnancy,
liver failure, venous obstruction
How long do you listen to bowel sounds before stating they are absent?
5 minutes
When assessing a pneumonia patient, which of the following lung sounds would the nurse expect to hear?
Crackles
The device used to test deep tendon reflexes (DTR) is..
reflex hammer
S4 heart sound may be expected in ______, ______, _______, but can be a sign of ________
children, adults
adults, children, athletes, concern
During an abdominal assessment, which of the following findings would be considered abnormal? (A) Visible pulsations in the abdomen (B) Symmetric abdominal contour (C) Soft, non-tender abdomen
(A) Visible pulsations in the abdomen (could indicate Abdominal aortic aneurysm)
During a respiratory assessment, the nurse auscultates the client's lung sounds. Which of the following findings would be considered abnormal? (A) Diminished breath sounds on one side (B) Bronchovesicular sounds heard over the lung fields (C) Vesicular sounds over the trachea and bronchi
(A) Diminished breath sounds on one side
A nurse caring for a client with a head injury performs all the following assessments. Which one is most important at this time? (A) assessing the lung sounds (B) assessing the pupillary responses (C) assessing the skin integrity (D) assessing the urine characteristics
B) assessing the pupillary responses
During the assessment of heart sounds, the nurse identifies a murmur that is described as a whooshing or blowing sound between normal heart sounds. What does this abnormal heart sound most likely indicate?
A murmur (also can be considered a valve stenosis, which is the narrowing of a heart valve, causing turbulent blood flow. )
Which of the following would be considered an abnormal finding during a visual assessment of the abdomen? (A) Silver white striae (B) Soft protrusion of the umbilicus (C) Scaphoid abdomen
(B) Soft protrusion of the umbilicus