Advanced Health Assessment - Exam 2 Latest

Advanced Health Assessment - Exam #2 Latest Update - Sources with 275 Questions and Verified Correct Answers Golden Ticket to Guaranteed A+ Verified by Professor

"Elevated" blood pressure range? - CORRECT ANSWER: 120-129 (Systolic) or (<80 diastolic)

• The nurse is percussing the seventh right intercostal space at the midclavicular line

over the liver. Which sound should the nurse expect to hear?a.Dullness b.Tympany c.Resonance d.Hyperresonance - CORRECT ANSWER: CORRECT ANSWER: A The liver is located in the right upper quadrant and would elicit a dull percussion note.

A 24-year-old man presents with sudden onset of left-sided scrotal pain. He reports having intermittent unilateral testicular pain in the past but not as severe this current episode. Confirmation of testicular torsion would include all of the following findings

except:

• unilateral loss of the cremasteric reflex.
• the affected testicle held higher in the scrotum.
• testicular swelling.
• relief of pain with scrotal elevation. - CORRECT ANSWER: D. relief of pain with

scrotal elevation.

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: 1 / 4

• Document the presence of hepatomegaly.
• Ask additional health history questions regarding his alcohol intake.
• Describe this dullness as indicative of an enlarged liver, and refer him to a physician.
• Consider this finding as normal, and proceed with the examination. - CORRECT

ANSWER: CORRECT ANSWER: D Consider this finding as normal A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

A 60-year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from cancer of the prostate, and he is concerned this will happen to him. How should the nurse respond?A)"The swelling in your prostate is only temporary and will go away." B)"We will treat you with chemotherapy so we can control the cancer." C)"It would be very unusual for a man your age to have cancer of the prostate." D)"The enlargement of your prostate is caused by hormone changes and not cancer." -

CORRECT ANSWER: CORRECT ANSWER: D

The prostate gland commonly starts to enlarge during the middle adult years. This benign prostatic hypertrophy (BPH) is present in 1 out of 10 males at the age of 40 years and increases with age. It is thought that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.

A 70-year-old man is visiting the clinic for difficulty in passing urine. In the history he indicates he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Given this history, what might the nurse expect to find during the physical assessment?A)Asymmetric, hard, fixed prostate gland B)Occult blood and perianal pain to palpation C)Symmetrically enlarged, soft prostate gland

D)A soft nodule protruding from rectal mucosa - CORRECT ANSWER: CORRECT

ANSWER: ASubjective symptoms of carcinoma of the prostate include frequency,

nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of 2 / 4

the prostate include a malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed

A 72-year-old male presents at a local clinic and states: "I have to urinate all the time, and I never feel like my bladder is emptied. It really bothers me at night." What condition might the nurse suspect related to this chief complaint? - CORRECT ANSWER: Benign prostatic hyperplasia (BPH)

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse interprets this as which of the following?

• Positive Rovsing's sign
• Psoas sign
• Obturator sign
• Positive skin hypersensitivity test - CORRECT ANSWER: A) Positive Rovsing's sign

A finding on palpation that suggests venous insufficiency is: - CORRECT ANSWER: Diminished dorsalis pedis pulse in an edematous foot

Venous insufficiency is associated with significant edema, and possibly diminished pedal pulses as a result. Ulceration, if present, tends to be on the sides of the foot and temperature is usually normal. Sensation does not tend to diminish.

A grade IV mitral regurgitation murmur would:

• be described as a diastolic murmur.
• not be expected to have a thrill.
• radiate to the axilla.
• be heard best at the base. - CORRECT ANSWER: CORRECT ANSWER: C

A grade IV murmur would have a thrill; and a mitral regurgitation murmur is best heard at the apex, is holosystolic, and would radiate to the axilla. 3 / 4

A grade IV mitral regurgitation murmur would:

• be described as a diastolic murmur.
• not be expected to have a thrill.
• radiate to the axilla.
• be heard best at the base. - CORRECT ANSWER: CORRECT ANSWER: C

A grade IV murmur would have a thrill; and a mitral regurgitation murmur is best heard at the apex, is holosystolic, and would radiate to the axilla.

A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following?

• It is a normal-sized liver.
• The liver is larger than normal.
• The liver is smaller than normal.

D) The liver has atrophied. - CORRECT ANSWER: A) It is a normal-sized liver.

A nurse recognizes that which finding is normal upon palpation of the prostate? -

CORRECT ANSWER: Nontender and rubbery

A palpable rushing vibration over the base of the heart at the second intercostal space

is called a:

• heave.
• lift.
• thrill.
• thrust. - CORRECT ANSWER: CORRECT ANSWER: C

A thrill is a fine, palpable, rushing vibration¯a palpable murmur. Cardiac thrills generally indicate a disruption of the expected blood flow related to some defect in the closure of one of the semilunar valves (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial septal defect. A heave or lift is a more vigorous apical impulse. A lift is another term for a heave, which is a more vigorous apical impulse. A thrust is sudden, forcible forward movement.

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