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NUR631-ADVANCED HEALTH ASSESSMENT TEST
2 |2025-2026|80Qs&As|GRADED A+:- D’youville
university
The nurse knows that a normal finding when assessing the respiratory system of an older adult is: A. Increased thoracic expansion B. Decreased mobility of the thorax C. Decreased anteroposterior diameter D. Bronchovesicular breath sounds throughout lungs B. Decreased mobility of the thorax Costal cartilage becomes calcified with aging Which of these statements in true regarding the vertebra prominens? The vertebra promenens is: A. The spinous process of c B. Usually nonpalpable in most individuals C. Opposite the interior border of the scapula D. Located next to the manubrium of the sternum A - spinous process of c7, landmark for counting ribs posteriorally When performing a resp assessment on a pt, the nurse notices a costal angle of approx. 90 degrees. This characteristic is:
A. Observed in pts with kyphosis B. Indicative of pecus excavatum C. A normal finding in a healthy adult D. An expected finding in a pt with barrel chest C. A normal finding in a healthy adult When assessing a pt's lungs, the nurse recalls that the left lung: A. Consists of two lobes B. Is divided by the hoizontal fissure C. Primarilly consists of an upper lobe on the posterior chest D. Is shorter than the right lung because of the underlying stomach. A. Consists of two lobes Which statement abut the apices of the lungs is true? A. Are at the level of the second rib anteriorly B. Extend 3-4cm above the inner third of the clavicles C. Are located at the sixth rib anteriorly and eight rib laterally D. Rest on the diaphragm at the fifth ics in the midclavicular line B. Extend 3-4cm above the inner third of the clavicles
A 65 year-old pt with a hx of chf comes to the clinic with compaints of being awakened from sleep with sob, which action by the nurse is most appropriate? A. Obtain a detailed hhx of pt allergies and hx of asthma B. Telling the pt to sleep on his or her right side to facilitate ease of respirations C. Assessing for other s/s of paroxysmal noctural dyspnea D. Assuring the pt that paroxsymal nocturnal dyspnea is normal and will probable resolve within the next week C. Assessing for other s/s of paroxysmal noctural dyspnea When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? A. B/w the scapulae B. 3rd ics, mcl C. 5th ics, mal D. Over the lower lobes, posterior side A. B/w the scapulae (and around sternum) The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? A. It is caused by moisture in the alveoli
B. Indicates that air is present in the subcutaneous tissues C. Is caused by sounds generated from the larynx D. Reflects the blood flow through the pulmonary arteries C. Is caused by sounds generated from the larynx During percussions, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: A. Shallow breathing B. Normal lung tissue C. Decreased adipose tissue D. Increased density of lung tissue D. Increased density of lung tissue The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultory site on the thorax to another is " " comparison. A. Side-to-side B. Top-to-bottom C. Posterior-to-anterior D. Interspace- by-interspace
The nurse is percussing over the lungs of a patient with pna. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: A. Dullness B. Tympany. C. Resonance D. Hyperresonance A. Dullness Pna, pleural effusin, atelectasis, tumor During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? A. When the bronchial tree is obstructed B. When adventitious breath sounds are present C. In conjunction with whispered pectoriloquay D. In conditions of consolidation, such as pna A. When the bronchial tree is obstructed
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions the nurses next action should be to: A. Assure the mother that these signs are normal for symptoms of a cold B. Recognize that these are serious signs, and contact the physician C. Ask the mother if the infant has had trouble with feedings D. Perform a complete cardiac assessments because these signs are probably indicative of early heart failure B. Recognize that these are serious signs, and contact the physician When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? A. Crepitus palpated at the costochondral junctions B. No diaphragmatic excursion as a result of a childs decreased inspiratory volume C. Presence of bronchovesicular breath sounds in the peripheral lung fields D. Irregular respiratory pattern and a rr of 40 breaths per minute at rest C. Presence of bronchovesicular breath sounds in the peripheral lung fields Chest walls and musculature not thick enough yet to dampen sound
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? A. In an obese patient B. When part of the lung is obstructed or collapsed C. When bulging of the ics is present D. When accessory muscles are used to augment respiratory effort B. When part of the lung is obstructed or collapsed During auscultation of the lungs of an adult pt, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? A. Airway obstruction B. Emphysema C. Pulmonary consolidation D. Asthma C. Pulmonary consolidation Bronchophony = enhanced tranmission of voice sounds
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? A. They are musical in quality B. They're usually caused by pathoogic disease C. They're expected near major airways D. They're similar to bronchial sounds except shorter in duration C. They're expected near major airways The nurse is listening to breath sounds of a pt with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A. Wheezing B. Bronchial sounds C. Bronchophony D. Whispered pectoriloquy A. Wheezing The sac that surrounds and protects the heart is called the:
A. Atria contract during systole and attempt to push against closed valves B. Contraction of the atria at the beginning of diastole can be felt as a palpitation C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole D. The atria contract toward the end of diastole and push the remaining blood into the ventricles D. The atria contract toward the end of diastole and push the remaining blood into the ventricles When listening to heart sounds, the nurse knows the valve closures that can be heard best as the base of the heart are: A. Mitral and tricuspid B. Tricuspid and aortic C. Aortic and pulmonic D. Mitral and pulmonic C. Aortic and pulmonic Which of these statements describes the closure of the valves in a normal cardiac cycle? A. The aortic valve closes slightly before the tricuspid valve B. The pulmonic valve closes slightly before the aortic
C. The tricuspid valve closes slightly later than the mitral D. Both the tricuspid and pulmonic valves close at the same time C. The tricuspid valve closes slightly later than the mitral The component of the conduction system referred to as the pacemaker of the heart is: A. Atrioventricular node B. Sinoatrial node C. Bundle of his D. Bundle branches B. Sinoatrial node The electrical stimulus of the cardiac cycle follows which sequence? A. Av node sa node bundle of his B. Bundle of his av node sa node C. Sa node av node bundle of his bundle branches D. Av node sa node bundle of his bundle branches C. Sa node av noda bundle of his bundle branches
A 25-year-old woman in her fifth month pregnancy has a blood pressure 100/70. In reviewing her previous examination, the nurse notes that her bp in her second month was 124/80. In evaluating this change, what does the nurse know to be true? A. This decline in bp is the result of peripheral vasodilation and is an expected change. B. Because of increased cardiac output, the blood pressure should be higher at this time. C. This change in blood pressure is not an expected finding because it means a decrease in cardiac output. D. This decline in blood pressure means a decreased in circulating blood volume, which is dangerous for the fetus A. This decline in bp is the result of peripheral vasodilation and is an expected change. In assessing a 70-year-old man, the nurse finds the following: bp 140/100; hr 104 bpm and slightly irregular; and the split s2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? A. Increasing in resting hr B. Increase in sbp C. Decrease in dbp D. Increase in dbp
B. Increase in sbp A 45-year-old man is in the clinic for a routine physical exam. During the recording of his hhx, the pt states that he has been having difficulty sleeping, i'll be sleeping great, and then i wake up and feel like i can't get my breath. The nurses best response to this would be: A. When was your last ekg? B. It's probably because it's been so hot at night C. Do you have any history of problems with your heart? D. Have you had a recent sinus infection or upper respiratory infection? C. Do you have any history of problems with your heart? In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? A. Family hx, htn, stress, age B. Personality type, high cholesterol, diabetes, and smoking C. Smoking, htn, obesity, diabetes, and high cholesterol D. Alcohol consumption, obesity, diabetes, stress, high cholesterol C. Smoking, htn, obesity, diabetes, and high cholesterol
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sounds with the bell of the stethoscope over the left carotid artery. This would indicated: A. Valvular disorder B. Blood flow turbulence C. Fluid volume overload D. Ventricular hypertrophy B. Blood flow turbulence During an inspection of the precordium of an adult pt, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggest a(n): A. Normal heart B. Systolic murmur C. Enlargement of the left ventricle D. Enlargement of the right ventricle D. Enlargement of the right ventricle
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A. Third l ics at mcl B. Fourth l ics at sternal border C. Fourth l ics anterior axillary line D. Fifth l ics mcl D. Fifth l ics mcl The nurse is examining a pt who has possible cardiac enlargement. Which statement about percussion of the heart is true? A. Percussion is a useful tool for outlining the heart borders B. Percussion is easier in pts who are obese C. Studies show that percussed cardiac borders do not correlate well with the true cardiac border D. Only expert health care providers should attempt percussion of the heart C. Studies show that percussed cardiac borders do not correlate well with the true cardiac border The nurse is preparing to auscultate for heart sounds. Which technique is correct?
