NR-302 Health Assessment I - Set 5 - Part 2

Correct Answer: Arterial stiffening widens pulse pressure but treatment is needed

Stiff arteries raise systolic pressure while diastolic plateaus, producing isolated systolic hypertension with a widened pulse pressure. The mechanism is age related, but the hypertension remains abnormal and is still evaluated and treated. Option b is incorrect because calling elevated pressure a normal variant is exactly the reasoning that leaves older adults untreated. Age explains why the pattern appears; it does not convert a treatable risk factor into a harmless finding. Option c is incorrect because the diastolic value here is low rather than high. Aging pushes the top number up while the bottom number stays flat or drifts down, which is the reverse of what this option claims. Option d is incorrect because orthostatic hypotension is diagnosed by comparing supine and standing measurements. A single seated reading says nothing about postural drop, which requires a fall of twenty systolic or ten diastolic points.

Correct Answer: A severe headache with blurred vision

Severe headache with visual disturbance sits at the center of the preeclampsia cluster, alongside epigastric pain, sudden facial or hand swelling, and hyperreflexia. That combination demands evaluation the same day rather than reassurance. Option a is incorrect because progesterone relaxes the lower esophageal sphincter and the growing uterus raises abdominal pressure. Reflux at this stage is predictable, and the nurse teaches smaller meals and upright positioning after eating. Option b is incorrect because hyperemic, softened gums that bleed with ordinary brushing are a recognized change of pregnancy. Dental care remains safe and recommended, though tooth decay and tooth loss are never accepted as normal. Option d is incorrect because relaxin softens pelvic ligaments and a shifting center of gravity produces lordosis. Positional low back pain fits that picture, whereas back pain with pelvic pressure and contractions would suggest preterm labor.

Correct Answer: The second rib on each side

The sternal angle, or angle of Louis, is the ridge where the manubrium meets the sternal body about five centimeters below the notch, and it is continuous with the second rib. Option b is incorrect because the first rib lies hidden behind the clavicle and cannot be palpated at all, which is precisely why counting starts at the sternal angle rather than higher on the chest. Option c is incorrect because counting downward one space from the ridge reaches the second intercostal space, not the third rib; each interspace carries the number of the rib immediately above it. Option d is incorrect because that rib sits well below the manubriosternal junction and offers no reliable surface ridge; a nurse who anchors there will misplace every landmark counted afterward.

Correct Answer: The lagging right side is the abnormal one

The side that lags is the abnormal side. Reduced expansion here suggests splinting from pain, atelectasis or a developing consolidation, all of which call for further assessment and pain control before the client stops breathing deeply. Option a is incorrect because reduced movement never indicates strength; a side that fails to expand is being held back by pain, collapse, fluid or an obstructed airway, and every one of those needs investigating. Option b is incorrect because postoperative clients often splint, yet asymmetry is still a finding to act on rather than to accept; untreated splinting leads directly to atelectasis and then to pneumonia. Option c is incorrect because the thumb traveling farther is simply the healthy side doing its normal work, and treating it as diseased would send attention to the wrong half of the chest.

Correct Answer: Found on floor, head to toe assessment done, provider notified

The chart carries what happened to the client, what the nurse assessed afterward, and who was told and when. That factual account is exactly what the next reader and any reviewer need. Option a is incorrect because naming the occurrence report inside the chart ties an internal risk document to the clinical record. That link can strip away whatever protection the report might otherwise have held. Option b is incorrect because staffing complaints belong in the chain of command, not in a client's chart. Writing them there turns the record into evidence against the unit and reads as an excuse. Option d is incorrect because the word apparently signals guesswork and the sentence assigns fault to a colleague. Blame language invites a reader to imagine negligence that the nurse never actually witnessed.

Correct Answer: Use the ulnar edge while the client repeats a phrase

The ulnar edge or the palmar base of the hand senses vibration best, and the client must repeat a resonant phrase such as ninety nine each time the hand is moved to a new pair of spots. Option a is incorrect because bone dampens vibration, so palpating over the shoulder blades produces false asymmetry; the scapulae are moved aside by folding the arms precisely so that lung, not bone, is examined. Option c is incorrect because fremitus is a palpated buzz rather than a listened sound, and swapping in an endpiece measures something different entirely while leaving the vibration itself unassessed. Option d is incorrect because a continuous sweep down one side never sets a matched pair side by side, and comparison between mirror image areas is the only way asymmetric fremitus becomes visible.

Correct Answer: Erythema extending two centimeters, purulent drainage, foul odor

Erythema measured in centimeters, drainage described by color and character, and the presence of odor are all observations another nurse can verify. The conclusion about infection belongs to the provider, not the note. Option a is incorrect because infection is a medical diagnosis and sits outside nursing documentation. The findings that pointed the nurse toward it, measured and described, are what the record needs so the provider can reach that conclusion. Option b is incorrect because worse is a comparison without any numbers behind it. Yesterday's measurements and today's measurements side by side show change, while a bare adjective leaves the next reader guessing at how much the wound grew. Option d is incorrect because healing poorly states a judgment about progress. Tissue type in the wound bed, the percentage of granulation, and the condition of the edges give the reader something concrete to track over days.

Correct Answer: Chronic bronchitis with overnight secretion pooling

Secretions collect in the airways overnight and are cleared with the first effort of the morning, which is the classic pattern of chronic bronchitis and of smoking related airway disease. Option a is incorrect because that drug produces a dry, tickly cough with no sputum at all, and it persists through the day rather than clearing once the airway has been emptied each morning. Option b is incorrect because reflux typically drives coughing when the client lies down at night, and the cough it causes is usually dry rather than loaded with the mucus described here. Option c is incorrect because scarring of lung tissue produces a persistent nonproductive cough accompanied by progressive breathlessness; sputum production is not a feature, so the morning clearing described does not fit.

Correct Answer: The midaxillary line

The midaxillary line drops from the apex, the deepest point of the axilla, and divides the lateral chest; it is also where the eighth rib marks the lateral lung base. Option a is incorrect because that line falls from the anterior axillary fold, the crease raised by pectoralis major, which sits forward of the axillary apex and would place the finding too far anteriorly. Option c is incorrect because the posterior axillary fold formed by latissimus dorsi anchors a line running behind the axilla, so charting it there would send another clinician to the wrong spot. Option d is incorrect because a line dropped from the midpoint of the clavicle covers the anterior chest surface, not the side, and it is used for the cardiac apex and anterior lung border.

Correct Answer: Abdominal movement counted for a full minute

Infants breathe with the diaphragm, so the abdomen rises and falls while the chest stays relatively still. Because their rate and rhythm vary, the count runs a full sixty seconds to be reliable. Option b is incorrect because thoracic movement becomes the dominant pattern only later in childhood. Halving the counting time also magnifies the error, since infant respirations are irregular enough that a partial count misleads. Option c is incorrect because periodic breathing with short pauses belongs to normal newborn physiology. Expecting metronomic regularity would prompt needless alarm, though a pause lasting twenty seconds or longer is genuinely apnea. Option d is incorrect because respirations are counted before the infant is disturbed, not afterward. An ear examination reliably produces crying, and the resulting rate reflects the child's outrage rather than baseline respiratory function.

Correct Answer: Group findings by position and split across sessions

Planning the sequence around position means everything sitting, then everything reclined, with one transition each way. Splitting the examination across two sessions gives a partial assessment done well rather than a full one done through exhaustion. Option a is incorrect because kyphosis and orthopnea make lying flat painful or impossible. Examining at thirty to forty-five degrees is the workaround, and one uninterrupted session ignores how fast this client's reserve runs out. Option c is incorrect because postponing assessment leaves the cause of her fatigue and dizziness unexamined. Orthostatic vital signs and a medication review are precisely what a client like this needs, and waiting only delays the answer. Option d is incorrect because repeated standing invites the fall the nurse is trying to prevent. Baroreceptor sensitivity declines with age, so transitions are assisted, limited, and preceded by dangling at the edge of the bed.

Correct Answer: Treat the upper process as the seventh cervical vertebra

When two processes stand out equally, the upper one is the seventh cervical vertebra and the lower is the first thoracic, so counting downward from the upper marker keeps every level correct. Option a is incorrect because the lower of the two prominences is the first thoracic vertebra, so every level counted below it would be labeled one number too low and each finding charted would be misplaced. Option b is incorrect because the inferior scapular angle serves only as a cross-check near the seventh rib; it cannot replace a starting point at the top of the spine when levels above it are needed. Option c is incorrect because that hollow sits atop the sternum and anchors anterior rib counting; reaching for it would require turning the client around and abandoning the posterior examination.

Correct Answer: Tachypnea, a rapid and shallow pattern

Tachypnea is a rate greater than twenty four breaths each minute, rapid and shallow. It follows fever, pain and fear normally, and accompanies pneumonia, pleurisy and respiratory insufficiency when it is abnormal. Option a is incorrect because a slow rate under ten each minute defines that pattern, and it points toward opioid or sedative effect, raised intracranial pressure or hypothyroidism rather than the rapid breathing counted here. Option b is incorrect because that pattern raises both rate and depth, producing the deep sighing breaths of metabolic acidosis; the shallow excursions described here move less air per breath, not more. Option d is incorrect because shallow breathing that is also irregular follows opioid or anesthetic effect, prolonged bed rest, or splinting against pain, and this client's rhythm was counted as regular throughout the minute.

Correct Answer: It carries the nurse's clinical impression of the problem

In this format the third section is the writer's conclusion, meaning the clinical impression or nursing diagnosis drawn from the first two. Data collection has already finished by the time that section begins. Option b is incorrect because extra measurements still count as objective data and belong in the second section with the vital signs. Adding them lower down splits the same category across two headings. Option c is incorrect because planned interventions occupy the fourth and final section of the note. Moving them up one position leaves the writer with nowhere to state what the gathered information actually means. Option d is incorrect because quoted symptoms are subjective and were already placed in the opening section. Repeating the nausea further down would duplicate one datum while leaving the writer's reasoning entirely unrecorded.

Correct Answer: Encircle the head above the brows and occiput

The tape sits at the largest circumference, running over the occipital protuberance behind and just above the eyebrows in front. Head circumference is measured routinely to age two and grows roughly one centimeter each month in year one. Option a is incorrect because the hairline sits above the true maximum and varies between infants. A tape placed there returns a value smaller than the real circumference, which can hide genuine growth failure on the chart. Option b is incorrect because a tape crossing the tops of the ears rides below the occipital prominence. That path shortens the loop and yields a falsely low reading that will not match repeat measurements. Option d is incorrect because the jaw belongs to facial measurement and has nothing to do with cranial growth. Head circumference tracks brain volume, so the tape must capture the skull at its widest point.

Correct Answer: Age related change from kyphosis and lost elastic recoil

Vertebral wedging and loss of elastic recoil round the aging thorax, so a barrel shape alone is expected here; normal resonance and the absence of any breathing complaint separate this from obstructive disease. Option a is incorrect because hyperinflated lung percusses hyperresonant rather than resonant, and this client also lacks the smoking history, prolonged expiration and accessory muscle use that obstructive disease brings with it. Option b is incorrect because narrowed airways trap air and give a hyperresonant note with prolonged expiration, yet the client here describes no attacks, no chest tightness and no difficulty breathing. Option c is incorrect because a sternum that caves inward or juts forward is present from childhood and looks quite different from a uniformly rounded thorax that developed slowly across the later decades of life.

Correct Answer: Perform a focused respiratory assessment and escalate

A steadily rising respiratory rate is the earliest measurable sign of deterioration. Holding the saturation at this level means the client is still compensating, and the number falls only once compensation gives out. Option a is incorrect because watchful waiting treats an unmistakable upward trend as though it were noise. Four consecutive rises in a row is a pattern, and the window for acting closes while the nurse waits. Option c is incorrect because swapping equipment tests a value that is currently within range. The alarming information sits in the respiratory rate, and confirming a normal saturation answers a question nobody asked. Option d is incorrect because breathing exercises address a symptom without ever identifying its cause. Pain, fever, anxiety, pneumonia and a clot all raise the rate, and coaching alone would mask a worsening problem.

Correct Answer: Asbestos from insulation and older building materials

Shipyards, insulation work and demolition are the classic settings for asbestos exposure, which produces pleural plaques, asbestosis and mesothelioma decades after the work ended and multiplies risk in a client who also smoked. Option b is incorrect because that dust comes from mining, quarrying, foundry work and stone countertop fabrication rather than from insulating ships, and it carries a raised tuberculosis risk not linked to this history. Option c is incorrect because pneumoconiosis of this type belongs to coal miners, and nothing in shipyard insulation work involves cutting or hauling coal underground, so the exposure history would not support that line of questioning. Option d is incorrect because organic material of that kind triggers hypersensitivity pneumonitis in farmers and bird keepers, an allergic reaction to inhaled protein rather than the fibrotic scarring that mineral fibers cause.

Correct Answer: Heart rate and respiratory rate both fall

Pulse and respiratory rates start highest in the newborn and settle downward year by year, while blood pressure climbs steadily toward adult values. A heart rate of one hundred forty fits an infant, not a schoolchild. Option a is incorrect because rates move downward with maturation, not upward. Reversing the direction would place the fastest pulse in the oldest child, which contradicts every pediatric reference range used at the bedside. Option c is incorrect because the two rates travel together in the same direction. Splitting them apart describes no normal developmental pattern, and a rising respiratory rate in an older child signals illness instead. Option d is incorrect because blood pressure rises through childhood as vessels and body size change. Pulse also changes substantially rather than holding steady, and pressure is not measured routinely until about age three.

Correct Answer: The client's response to the analgesic given

Focus charting closes with the response, which records whether the intervention worked. Reassessing the pain score after the medication and writing what the client reports completes the entry and the nursing process. Option a is incorrect because the medication order lives in the order set and the administration record. Copying it into a progress note duplicates information and still leaves the effect of the drug unrecorded. Option b is incorrect because this format lets the focus be a symptom, an event or a change, so a formal diagnosis is optional. Choosing acute pain as the focus was already an acceptable choice. Option c is incorrect because a future appointment time is part of the plan of care, not part of this entry. The note is asking what happened to the client after the drug was given.