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Question
A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements?a. A problem exists with the sensory cortex and its ability to discriminate the location.
b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain.
c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.
d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.
Answer
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Related questions
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The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
a. To measure the rate of lymphatic drainage
b. To evaluate the adequacy of capillary patency before venous blood draws
c. To evaluate the adequacy of collateral circulation before cannulating the radial artery
d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
Q:
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should:
a. Check for the presence of claudication.
b. Refer the individual for further evaluation.
c. Consider this finding as normal, and proceed with the peripheral vascular evaluation.
d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
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When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?
a. Document the finding.
b. Auscultate the site for a bruit.
c. Check for calf pain.
d. Check capillary refill in the toes.
Q:
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 approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
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A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
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The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
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d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
Q:
Which statement is true regarding the arterial system?
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d. Arteries can greatly expand to accommodate a large blood volume increase.
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The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:
a. Normal for this age.
b. Lower than expected.
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During a cardiovascular assessment, the nurse knows that a thrill is:
a. Vibration that is palpable.
b. Palpated in the right epigastric area.
c. Associated with ventricular hypertrophy.
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During a cardiac assessment on a 38-year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?
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In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
a. Bell of the stethoscope at the base with the patient leaning forward.
b. Bell of the stethoscope at the apex with the patient in the left lateral position.
c. Diaphragm of the stethoscope in the aortic area with the patient sitting.
d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.
Q:
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?
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c. This change in blood pressure is not an expected finding because it means a decrease in cardiac output.
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b. Instructing the patient to breathe in and out through his or her nose
c. Firmly holding the diaphragm of the stethoscope against the chest
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Q:
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
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c. Decreased adipose tissue.
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Q:
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During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:
a. Costal angle.
b. Sternal angle.
c. Xiphoid process.
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Q:
When assessing a patient's lungs, the nurse recalls that the left lung:
a. Consists of two lobes.
b. Is divided by the horizontal fissure.
c. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.
Q:
A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?
a. Absent or decreased breath sounds
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Q:
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?
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Q:
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
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b. Pneumonia.
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d. Pulmonary edema.
Q:
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
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b. Atelectasis.
c. Lobar pneumonia.
d. Heart failure.
Q:
A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, during assessment the nurse will most likely observe:
a. Testes that are hard and painful to palpation.
b. Atrophic scrotum and a bilateral absence of the testis.
c. Absence of the testis in the scrotum, but the testis can be milked down.
d. Testes that migrate into the abdomen when the child squats or sits cross-legged.
Q:
Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man?
a. "Do you need to get up at night to urinate?"
b. "Do you experience nocturnal emissions, or "wet dreams'?"
c. "Do you know how to perform a testicular self-examination?"
d. "Has anyone ever touched your genitals when you did not want them to?"
Q:
In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?
a. Hyperreflexia
b. Fasciculations
c. Loss of muscle tone and flaccidity
d. Atrophy and wasting of the muscles
Q:
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
a. Scissors gait
b. Cerebellar ataxia
c. Parkinsonian gait
d. Spastic hemiparesis
Q:
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response:
a. Indicates a lesion of the cerebral cortex.
b. Indicates a completely nonfunctional brainstem.
c. Is normal and will go away in 24 to 48 hours.
d. Is a very ominous sign and may indicate brainstem injury.
Q:
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?
a. This response could indicate brachial nerve palsy.
b. This reaction is an expected startle response at this age.
c. This reflex should have disappeared between 1 and 4 months of age.
d. This response is normal as long as the movements are bilaterally symmetric.