The nurse is performing the technique shown. What is the nurse assessing?

Tactile fremitus

Chest expansion

Breath sounds

Tissue consolidation

Answer and Explanation

The Correct Answer is B

A. Tactile fremitus: This involves palpating vibrations on the chest wall as the patient speaks, not assessing chest expansion.

B. Chest expansion: This technique assesses the symmetrical movement of the chest during inhalation and exhalation, which is the correct assessment for this context.

C. Breath sounds: Breath sounds are assessed through auscultation rather than palpation.

D. Tissue consolidation: This involves detecting areas of increased density in lung tissue, often assessed through percussion or auscultation, not through the technique shown for chest expansion.

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Correct Answer is B

Explanation

A. S2: This sound, also known as "dub," occurs during diastole when the semilunar valves close.

B. S1: This sound, also known as "lub," occurs during systole when the atrioventricular valves close, marking the beginning of systole.

C. S4: This sound is an abnormal heart sound associated with late diastole, not systole.

D. S3: This sound is associated with early diastole and is typically related to rapid ventricular filling, not systole.

A. History of present illness B. Initial Information C. Review of Systems D. Health Patterns

Correct Answer is A

Explanation

A. History of present illness: The OLD CART mnemonic is used to evaluate the characteristics of a symptom, which is documented under the history of present illness.

B. Initial Information: This section includes basic demographic and background information rather than detailed symptom analysis.

C. Review of Systems: This section includes a systematic review of body systems and their functions, not the detailed attributes of a specific symptom.

D. Health Patterns: This section covers the client’s overall health patterns and lifestyle but not the detailed attributes of a specific symptom.

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The nurse is performing the technique shown. What is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the cardiac cycle, heart sounds correlate with events of the cycle. Which is being associated with systole?

Correct Answer is B

Explanation

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

Correct Answer is A

Explanation

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer?

A patient is unable to taste in the 2/3 anterior of his tongue. Which cranial nerve is affected?

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

A positive Murphy's sign is indicative of?

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

The nurse is using the finger pads of the hand to palpate a body part. The nurse would best be able to detect which finding?