NR-302 Health Assessment I - Set 5 - Part 1

Correct Answer: New confusion with a respiratory rate of thirty two

Altered mental status together with rapid breathing in a client who has an infection points toward sepsis and failing gas exchange. Both elements are new, and both change the plan of care immediately. Option a is incorrect because fever is one of the defining features of pneumonia and was anticipated on admission. Documenting it and following the trend is appropriate, so an urgent call adds nothing the provider does not expect. Option b is incorrect because crackles over consolidated lung tissue are the auscultatory hallmark of this diagnosis. A sound that fits the illness the client already carries goes into the note rather than into a page. Option d is incorrect because rust colored sputum is classically produced by pneumococcal infection of the lung. Its presence supports the working diagnosis instead of signaling a change that would alter what has already been ordered.

Correct Answer: One reporting new crushing pressure across the chest

New chest pressure is a circulation problem that may be evolving right now, and it is both sudden and unexpected. The nurse goes in, obtains vital signs, and escalates without waiting. Option b is incorrect because helping a client to the bathroom is a fall risk needing prompt attention, yet risk of harm later ranks under harm occurring now. This client can be delegated safely to assistive personnel. Option c is incorrect because a scheduled analgesic for long standing knee pain is stable and predictable. Chronic complaints that have not changed sit at the bottom of the sorting order every time. Option d is incorrect because teaching is a third level need that can be scheduled for later in the shift. Nothing in a request to review paperwork threatens breathing, circulation or immediate physical safety.

Correct Answer: The findings match the expected respiratory changes

Tidal volume rises by roughly a third and the diaphragm sits higher, so mild exertional breathlessness and a slightly faster rate are expected. Dyspnea at rest, orthopnea, or chest pain would change that judgment. Option a is incorrect because embolism announces itself with sudden dyspnea at rest, pleuritic chest pain, tachycardia, and often unilateral calf swelling. Pregnancy does raise clot risk, but this gradual exertional pattern carries none of those markers. Option b is incorrect because a failing heart in pregnancy produces orthopnea, paroxysmal nocturnal breathlessness, and a new third or fourth sound with crackles. This client lies flat all night, which argues strongly against that diagnosis. Option d is incorrect because asthma brings wheeze, cough, and chest tightness that respond to a bronchodilator. Nothing described here fits obstruction, and prescribing an inhaler for physiologic hyperventilation treats a condition the client does not have.

Correct Answer: Pause and let the client breathe normally

Breathing deeply through many sites blows off carbon dioxide and produces lightheadedness, circumoral tingling and occasionally fainting. Stopping until normal breathing returns settles the symptoms, and the examination resumes with fewer sites if needed. Option b is incorrect because pushing on through the remaining sites keeps the client hyperventilating and risks a faint from a seated position. Speed does not fix the problem that the deep breathing created. Option c is incorrect because supine positioning reduces lung volume and is reserved for clients who are hypoxic or unstable. This client has too little carbon dioxide, not too little oxygen, so oxygen changes nothing. Option d is incorrect because these sensations are an expected consequence of examiner directed deep breathing and resolve within minutes of stopping. Escalating them as a neurological event would alarm the client without cause.

Correct Answer: Visit during off duty hours if the neighbor agrees

Record access is limited to clients in the nurse's care and to purposes tied to that care. Visiting as a friend, with the neighbor's agreement, keeps the relationship outside the clinical record entirely. Option a is incorrect because opening a chart out of concern is still unauthorized access. Audit logs record every entry into a record, and organizations dismiss staff for exactly this, however kind the motive. Option b is incorrect because asking a colleague for information moves protected details to someone with no role in that client's treatment. The route of disclosure changes, but the breach is identical. Option d is incorrect because limiting the reading to one field does not create authorization. Permission rests on whether the nurse is caring for that client, never on how little of the record gets viewed.

Correct Answer: Entries made near the event carry far greater weight

Memory fades within minutes, so a note written close to the care is both more accurate and more persuasive years later. Waiting until the end also leaves the next shift working without current information. Option a is incorrect because a countersignature is not what makes a late entry acceptable. What the record needs is the label identifying the entry as late together with the hour the care actually occurred. Option b is incorrect because records stay open for legitimate additions and amendments after a shift ends. Timeliness matters because of accuracy and communication, not because a system slams a door at seven o'clock. Option c is incorrect because prompt charting usually produces more detail, not less. Length is beside the point, since the note has to be complete, and detail recalled hours afterward is thinner and easier to challenge.

Correct Answer: Only the three-year-old needs the least distressing parts first

The reversal belongs to young children who cannot cooperate: quiet auscultation first, ears and mouth last. By school age a child manages the standard head to toe order, and so does the adult. Option b is incorrect because a three-year-old will not sit through a systematic regional sweep. Applying one sequence to every age ignores the reason pediatric order exists, which is the child's tolerance rather than anatomy. Option c is incorrect because the otoscopic examination is the single most intrusive part for a small child. Placing it first destroys the calm needed for heart and lung sounds and wastes the quiet window entirely. Option d is incorrect because saving the ears for last is a pediatric strategy, not an adult one. Adults tolerate any order, so the modification exists for the toddler and preschooler who cannot.

Correct Answer: Place the diaphragm firmly against bare skin

Cloth muffles the sound the nurse needs and rustles enough to imitate crackles. Firm, full rim contact of the diaphragm on bare skin selects the higher frequencies of breath sounds and shuts out room noise. Option a is incorrect because fabric between the endpiece and the chest attenuates real findings while adding a rustling noise. Privacy is protected by draping the rest of the body, not by listening through clothing. Option b is incorrect because the bell is built for low frequency sounds such as certain heart murmurs. Breath sounds sit in the higher range, so the bell has no routine place in a lung examination. Option d is incorrect because nasal breathing creates upper airway turbulence that travels down the chest and masks quieter lung sounds. The client should be shown how to breathe through an open mouth instead.

Correct Answer: New instrumental loss is an early decline signal

Instrumental activities such as medications and finances demand executive function, so they fail before bathing or dressing. A new inability to do what she did last month is the most sensitive early sign of illness. Option a is incorrect because intact bathing tests only the physical layer of self-care. Katz items stay normal long after Lawton items slip, so relying on them alone conceals the decline already visible in this history. Option b is incorrect because the sequence runs the other way. Shopping, cooking, transport, medications, and money go first because each needs memory, sequencing, and judgment, while feeding and transferring survive much longer. Option c is incorrect because dismissing money trouble as ordinary aging misses both cognitive decline and financial exploitation. Either possibility carries serious consequences, and both are identified only by asking questions the nurse would otherwise skip.

Correct Answer: That level marks the normal upper border of liver dullness

Liver dullness begins near the fifth interspace in the right midclavicular line and continues downward, which is an expected border rather than disease; knowing the normal borders keeps students from charting healthy findings as abnormal. Option b is incorrect because the heart produces dullness on the left of the sternum between roughly the third and fifth interspaces, so a right sided finding cannot be explained by cardiac position. Option c is incorrect because gas in the stomach lies on the left at about the sixth interspace and gives a loud drumlike tympany, a sound nothing like the muffled thud the student elicited. Option d is incorrect because lung tissue reaches the sixth rib anteriorly in that line, so the student was still over lung when the note changed; the change reflects the organ underneath instead.

Correct Answer: A left sided pneumothorax

Percussion is the tiebreaker when fremitus and expansion are both reduced. Hyperresonance means excess air in the pleural space, so this is a pneumothorax rather than a collection of fluid. Option a is incorrect because fluid in the pleural space replaces air and gives a dull or flat note, which is the exact opposite of the booming quality the nurse elicited on that side. Option c is incorrect because solid lung transmits vibration well, so consolidation raises fremitus and percusses dull; both findings here run in the opposite direction from what pneumonia would produce. Option d is incorrect because collapsed lung loses volume, so the note over it turns dull and the trachea is pulled toward the affected side rather than air expanding that hemithorax.

Correct Answer: Whether it is louder over the neck

Stridor arises in the larynx or trachea, so it is louder when the stethoscope sits over the neck than over the chest wall. A wheeze, generated below, is loudest across the lung fields. Option a is incorrect because neither stridor nor a true wheeze clears with coughing, so the manoeuvre separates nothing here. Coughing is useful for telling secretions apart from fluid, not for locating an obstruction. Option b is incorrect because clients with either problem avoid lying flat once the work of breathing rises. Positional preference grades severity rather than pointing to where along the airway the narrowing sits. Option c is incorrect because saturation falls late in both upper and lower airway obstruction and can stay normal while a client deteriorates. A number tells the nurse nothing about the site of the noise.

Correct Answer: Both changes come from normal pregnancy pigmentation

Hormonal stimulation of melanocytes produces linea nigra, darkened areolae and nipples, chloasma, and darkened nevi. These pigment changes are expected, harmless, and fade substantially after delivery, so teaching and reassurance are what the client needs. Option b is incorrect because hepatic disease is not signaled by midline abdominal darkening or areolar pigment. Spider angiomas and palmar erythema are the pregnancy findings investigated for liver disease outside pregnancy, and even those are expected here. Option c is incorrect because no nutrient deficiency darkens skin in this specific midline and areolar distribution. Sending a well woman for laboratory work over an expected pigment change adds cost and worry without adding information. Option d is incorrect because prenatal vitamins cause constipation and nausea, not patterned hyperpigmentation. Stopping them on this reasoning would remove folate and iron from a pregnancy that genuinely depends on both.

Correct Answer: Fine crackles from fluid in small airways

Fine crackles are high pitched and very brief, occur at end inspiration as fluid filled small airways pop open, and persist after coughing. Heart failure, pneumonia and fibrosis all produce them. Option a is incorrect because coarse crackles are loud, low pitched and bubbling, begin early in inspiration, and often soften temporarily when the client clears secretions. Both the timing and the response to coughing differ here. Option b is incorrect because atelectatic crackles vanish after a few deep breaths or a change of position, which is exactly the test this client already failed. Persistence marks them as a real finding. Option d is incorrect because rhonchi are continuous and musical rather than discontinuous, sounding like low pitched snoring across the cycle. The popping quality described belongs to a crackle, not a rhonchus.

Correct Answer: Very little air is actually moving

Sound requires airflow. When effort is high and the chest is nearly silent, air is barely moving through the airways, which is far more ominous than a noisy chest full of wheezes. Option a is incorrect because a clear chest belongs to a comfortable client breathing easily with good air entry. Here the visible work of breathing contradicts the quiet, and the quiet is the warning. Option c is incorrect because badly angled earpieces muffle everything the nurse listens to, including heart sounds and bowel sounds. That artefact would not appear alongside diaphoresis and neck muscle recruitment in one client. Option d is incorrect because clearing secretions leaves audible breath sounds behind, often improved ones. Disappearance of all sound in a struggling client points to failing airflow rather than a successfully cleared airway.

Correct Answer: The anteroposterior diameter is about half the transverse diameter

A healthy adult thorax is elliptical in cross section, with the front to back measurement roughly half the side to side measurement, and the ribs sloping downward at about forty five degrees. Option a is incorrect because a rounded chest with those two measurements equal describes the barrel shape of chronic air trapping, and it is expected only in infancy and to a mild degree with aging. Option b is incorrect because no healthy chest is deeper than it is wide; reversing the proportion in that direction would place the sternum far forward of any shape the thoracic cage actually takes. Option d is incorrect because even a modest excess of depth over width signals hyperinflation rather than health, and the expected adult thorax remains clearly wider from side to side than it is deep.

Correct Answer: Discuss evaluation for vertebral compression fracture

Some height loss follows disc thinning, but a drop of about two inches from peak points to vertebral compression fractures. That degree of loss warrants osteoporosis evaluation rather than reassurance, and height is remeasured at every visit. Option a is incorrect because ordinary disc narrowing accounts for roughly one to two centimeters per decade. Two inches exceeds that comfortably, so charting it as expected buries a finding that should trigger bone density testing. Option b is incorrect because blanket reassurance is the classic trap in geriatric assessment. Telling a woman that everyone shrinks closes the conversation before anyone asks about back pain, fracture history, or calcium and vitamin D intake. Option c is incorrect because a tape held against the wall is less accurate than the stadiometer already used. Repeating a measurement with poorer equipment does not resolve doubt, and the clinical concern remains regardless of the second number.

Correct Answer: Close the door, lower pitch, and rephrase questions

Presbycusis destroys high frequencies, so shouting makes speech harder to follow. Cutting corridor noise, dropping the pitch, facing the client with light on the face, and rephrasing rather than repeating recovers the conversation. Option b is incorrect because volume raises pitch, which lands precisely in the range presbycusis has already taken. Shouting also distorts the mouth, removes lip-reading cues, and is heard by many clients as anger. Option c is incorrect because history belongs to the client, and turning to a relative strips away both accuracy and dignity. Collateral information is gathered afterward, with permission, once the client has told her own story. Option d is incorrect because untreated hearing loss is routinely misread as dementia or non-adherence. Charting impairment before checking cerumen, hearing aid batteries, and the noise level records a conclusion the nurse has not earned.

Correct Answer: Turn the client onto her left side

The gravid uterus compresses the vena cava and aorta when a client lies flat, cutting venous return. Rolling her to the left, or wedging the right hip, relieves the obstruction and restores cardiac output within moments. Option a is incorrect because measuring while the compression continues delays the one move that fixes it. Assessment matters, but a client who is symptomatic from position is repositioned first and measured afterward. Option b is incorrect because raising the head does nothing about a uterus resting on the inferior vena cava. Lateral displacement is what lifts the weight off the vessel, and elevation alone leaves the client symptomatic. Option c is incorrect because the problem is mechanical obstruction of venous return rather than a shortage of inspired oxygen. Supplemental gas cannot reach tissues when preload has collapsed, so position correction has to come first.

Correct Answer: The order groups tasks and prevents missed findings

A fixed order makes the examination self checking, so nothing is left out, and grouping stations by position spares the client repeated moves between sitting, lying and standing. Efficiency and comfort follow from that. Option a is incorrect because illness does not travel downward through the body in any orderly way. The sequence answers a practical problem about omission and client tolerance, and has nothing to do with pathology. Option c is incorrect because payers ask for specificity and completeness, not a particular anatomic route through the body. Reimbursement shapes how much detail appears in a note, never the physical order of the stations. Option d is incorrect because a stethoscope, an otoscope and a reflex hammer carry no built in sequence. Tools are picked up when the station calls for them, which is a consequence of the order rather than its cause.