ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 27 : Health Assessment Questions
Question 1 of 5
The nurse is caring for a patient experiencing bronchospasm due to an exacerbation of asthma. During auscultation, the nurse anticipates the presence of which breath sound?
Correct Answer: B
Rationale: Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways, such as with bronchospasm found in asthma or COPD. Rhonchi are low-pitched, continuous sounds with a snoring quality, which may clear with coughing; they occur when air passes through secretions. Crackles are discontinuous bubbling, cracking, or popping, low- to high-pitched sounds, that occur when air passes through fluid in the airways.
Question 2 of 5
A nurse in the emergency department is using the Glasgow coma scale to assess a patient who was struck in the head and upper body with a baseball bat. Based on the information in the neurologic assessment, what numerical value will the nurse assign?
Correct Answer: B
Rationale: Eye opening to painful stimulus = 2 points, no speech = 1 point; and withdrawal to painful stimulus = 4 points, for a total score of 7. A score of 8 or less is associated with coma.
Question 3 of 5
A nurse is caring for a patient with exacerbation of COPD and pneumonia. When auscultating the lungs, coarse expiratory, low-pitched, and continuous sounds that clear with coughing are present. How will the nurse document this breath sound in the electronic health record?
Correct Answer: A
Rationale: Rhonchi are abnormal low-pitched, continuous breath sounds auscultated during inspiration and occasionally expiration, indicating that air is passing through or around secretions. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Stridor is a harsh, loud, high-pitched sound auscultated on inspiration indicating narrowing of the upper airway or presence of a foreign body. Bronchial sounds are normal blowing, hollow sounds, auscultated over the larynx and trachea.
Question 4 of 5
A nurse is assessing a patient's eyes for accommodation. Place the steps of this assessment in the order they are performed.
Correct Answer: C,E,B,D,A
Rationale:
To test accommodation the nurse holds the forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 inches) from the bridge of the patient's nose. The patient is asked to look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object. The patient must be cooperative to complete this assessment. The results are documented last.
Question 5 of 5
A nurse is performing a breast assessment using the circular technique for palpation, gently compressing the breast tissue against the chest wall. How does the nurse proceed with the examination?
Correct Answer: A
Rationale: During breast assessment, the nurse palpates each quadrant of the breasts in a systematic method using the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse begins at the tail of Spence and moves in increasingly smaller circles. In the wedge method, the nurse works in a clockwise direction and palpates from the periphery toward the areola. In the vertical strip method, the nurse begins at the outer edge of the breast, palpating up and down the breast.