NR-304 Health Assessment II - Set 1 - Part 1

Correct Answer: Resonance, the normal lung note

Resonance is loud, low in pitch and long, and it is the expected note over air-filled healthy lung. The properties move together across the series, so more air makes a note louder, lower and longer. Option a is incorrect because tympany is high pitched and musical, like a drum, and comes from air trapped in a walled chamber such as the stomach or a bowel loop. Over the chest it would be abnormal. Option b is incorrect because flatness is soft, high pitched and short, arising from dense tissue holding no air at all. The thigh is the usual reference for it, not an aerated lung field. Option c is incorrect because dullness sits in the middle of the series, medium in loudness, pitch and duration, and marks a solid organ. Hearing it over healthy lung would raise concern for consolidation.

Correct Answer: Three plus, an increased and abnormal amplitude

On the course scale of zero to three plus, three plus is increased, full and bounding, and it is abnormal. Fever and anemia raise cardiac output and widen pulse pressure, producing this finding. Option b is incorrect because two plus is the normal amplitude of a pressure wave delivered through a patent vessel at an adequate stroke volume, and a pulse described as full and bounding exceeds that. Option c is incorrect because no four plus grade exists on the zero to three plus scale this course uses; students who carry a wider scale from another text reach for a grade that is unavailable here. Option d is incorrect because a weak, thready pulse reflects low stroke volume or a narrowed lumen, as in shock, peripheral arterial disease or decreased cardiac output, which is the opposite of what was palpated.

Correct Answer: The diaphragm, held lightly against the skin

Bowel sounds are auscultated with the diaphragm, which this course keys as the correct endpiece for the abdomen. The Blueprint also directs holding the stethoscope lightly, because pressing hard can stimulate additional bowel sounds and falsify the finding. Option a is incorrect because the bell transmits low-frequency sound and is reserved for gallops, mitral stenosis and bruits. Bowel sounds are auscultated with the diaphragm, so choosing the bell selects the wrong frequency filter entirely. Option b is incorrect because a bell forced into the skin stretches that skin until it behaves like a diaphragm, losing its low-pitched advantage. It is also the wrong endpiece for an abdominal assessment in the first place. Option d is incorrect because heavy pressure over the abdominal wall stimulates peristalsis and adds sounds the client was not making. Coiled tubing touching a bedrail or gown adds friction noise that masks quiet gurgles.

Correct Answer: Stop palpating and refer the client

An enlarged spleen ruptures easily, so the rule is to stop palpating and refer once enlargement is felt. Continuing to press, percuss or repeat the maneuver risks injuring an organ that is already distended and fragile. Option a is incorrect because deep pressure over a swollen spleen is precisely what can rupture it. Defining the border adds nothing that imaging cannot supply safely once the client has been referred. Option b is incorrect because percussion still applies repeated force to the same fragile organ. The finding has already been made, and further bedside technique cannot change the response, which is to stop and refer. Option c is incorrect because a deep breath pushes the spleen downward against the examining hand, increasing rather than reducing the force on it. That technique is used to find an organ, not after one is found.

Correct Answer: Dorsalis pedis pulse 1+ or absent

Relief by dependency and worsening with elevation is the arterial pattern, because gravity supplies the perfusion pressure a narrowed artery lacks. A cool hairless foot fits, and the pulse below the lesion is weak or gone. Option b is incorrect because hemosiderin staining comes from red cells pushed out of capillaries by sustained venous pressure. That client's pain would ease with elevation, which is the opposite of what this client describes. Option c is incorrect because arterial disease produces little or no edema; the limb is starved rather than congested. Firm pitting swelling of the whole calf belongs to a drainage failure, not to a delivery failure. Option d is incorrect because warmth and heavy exudate require blood that is still arriving in normal volume. A foot already described as cool cannot generate a weeping wound, and this stem reports coolness.

Correct Answer: Verbal five, oriented to person, place, time

The Glasgow verbal score of five anchors to the classic triad of person, place and time. Situation belongs to the oriented times four convention this course charts, and its absence does not lower the Glasgow verbal score. Option a is incorrect because it imports a charting convention into a scoring instrument. The two belong to different tools, and the Glasgow verbal anchor never asked the client to explain why he is here. Option b is incorrect because confused conversation means the client talks but gets the person, the place or the date wrong. This client answered all three correctly, so nothing in the exchange was disoriented. Option d is incorrect because that score describes random or exclamatory words with no sustained exchange. Coherent sentences naming himself, the building and the date are far above that level of verbal response.

Correct Answer: A positive Homans sign

Calf pain elicited by passive dorsiflexion of the foot with the knee extended is named Homans sign. The sign is unreliable and cannot rule deep vein thrombosis in or out, so it is named but never relied upon. Option a is incorrect because the Stemmer sign is tested at the base of the second toe or finger, where the examiner tries to tent a fold of skin. It identifies lymphedema, not a venous clot. Option c is incorrect because the Trendelenburg test assesses valve competence by emptying the leg veins, applying a tourniquet and watching how the veins refill on standing. It involves no dorsiflexion of the ankle at all. Option d is incorrect because the Allen test checks collateral arterial supply to the hand by compressing the radial and ulnar arteries and releasing one of them. Nothing about it concerns the calf or the deep leg veins.

Correct Answer: Walk to moderate pain, rest, then resume walking

Supervised exercise therapy has the client walk to the point of moderate claudication, rest until symptoms subside, then resume, for thirty to forty five minutes several times weekly, which builds collaterals and improves pain free distance. Option b is incorrect because stopping at the first twinge keeps the muscle below the stimulus that drives collateral development, so the program loses the very mechanism that lengthens walking distance. Option c is incorrect because seated ankle movement is taught to clients who cannot walk at all, while walking remains the best foot exercise and is the intervention with evidence behind it for claudication. Option d is incorrect because pushing on through severe pain risks tissue injury and is not what the protocol describes; sessions are built from repeated cycles of walking and rest, not one unbroken hour.

Correct Answer: A venous stasis ulcer relieved by elevation

Irregular edges, a shallow weepy base at the medial malleolus, brown hemosiderin staining, a warm limb and two plus pulses are the venous picture, and elevation drains the congested veins and relieves it. Option a is incorrect because an arterial ulcer is deep and dry with round punched out edges, sits on the toes, metatarsal heads, heel or lateral malleolus, and lies in a cold limb with diminished pulses. Option b is incorrect because neuropathic ulcers form at repetitive pressure points such as the plantar surface under the metatarsal heads, accompanied by sensory loss and foot deformity, not at the medial ankle with heavy exudate. Option c is incorrect because pressure injuries develop over bony prominences that bear weight during immobility, such as the sacrum or heel, and nothing in this assessment points to sustained external pressure at that site.

Correct Answer: The first is three plus and the second four plus

Depth alone never settles a grade; duration and the limb's appearance do. A pit that remains a short time in a swollen leg is three plus, and a lasting pit in a grossly distorted leg is four plus. Option a is incorrect because the two descriptions differ in both variables the scale uses. One leg merely looks swollen while the other is grossly distorted, and one pit resolves while the other persists. Option b is incorrect because it reverses the two grades. Deep pitting that subsides after a short time is the lower of the pair, and grossly swollen with a long lasting indentation is the higher. Option d is incorrect because this course anchors its grades to descriptors rather than to millimeters. Pit depths in millimeters appear in review books but in no major clinical reference, and they are not the wording tested here.

Correct Answer: The open ulcer on the toe tip

An open ulcer is tissue loss, the most advanced stage of arterial disease and chronic limb threatening ischemia. About half of diabetic foot ulcers become infected and roughly one in five leads to amputation. Option a is incorrect because thick, ridged, slow growing nails are a trophic change from a starved nail matrix; they document chronic ischemia but carry no immediate threat to the limb. Option b is incorrect because loss of toe hair is the earliest trophic change of arterial insufficiency and is valuable for staging the disease, yet it is not an urgent problem needing action today. Option c is incorrect because an unbroken blister must still be reported and protected, but skin that remains closed ranks below established tissue loss when the nurse sets priorities for this foot.

Correct Answer: Support the client's arm during palpation

An axilla cannot be palpated while the client holds the arm up, because the muscles stay contracted and the fascia taut. Supporting the flexed elbow on the examiner's forearm relaxes the shoulder girdle and lets the fingers reach the apex. Option a is incorrect because the axillary examination is performed with the client sitting, which lets the examiner reach high into the apex from the side. Lying flat is the position used for the breast tissue itself. Option b is incorrect because the sweep starts high in the apex and works downward through central, pectoral, subscapular and lateral groups. Starting at the humerus skips the central nodes, which usually enlarge first. Option d is incorrect because heavy pressure pushes a small node aside and obliterates it. Nodes are found with the pads of two or three fingers moving the skin gently over the underlying tissue.

Correct Answer: Raynaud phenomenon triggered by cold exposure

Raynaud phenomenon is episodic vasospasm of digital arteries producing white from arteriospasm, blue from a slow trickle with heavy oxygen extraction, then red from reactive hyperemia, triggered by cold, vibration or stress. Option b is incorrect because an acute occlusion strikes one limb or digit suddenly and does not resolve on its own; Raynaud attacks are bilateral, last minutes to hours and reverse completely with rewarming. Option c is incorrect because cellulitis gives a fixed red, hot, swollen and tender area that does not blanch to white or cycle through colors, and it is not provoked by handling something cold. Option d is incorrect because venous insufficiency affects the legs, produces brown pigmentation, brawny edema and thickened skin over time, and has no episodic color sequence tied to a cold trigger.

Correct Answer: Smoking cigarettes over many years

Smoking is the strongest modifiable risk factor for peripheral arterial disease, raising risk about fourfold, because tobacco constricts arteries, increases coagulability, injures the endothelium and promotes the inflammation that propagates plaque. Option a is incorrect because sodium intake acts mainly through blood pressure, which sits third on the ranked risk list; it contributes to arterial disease indirectly and nowhere near as powerfully as tobacco. Option c is incorrect because a sedentary pattern does appear on the risk list, grouped with obesity near the bottom, so reducing sitting helps but is not the habit with the largest effect. Option d is incorrect because alcohol use is not among the ranked risk factors the course teaches for this disease, which run from smoking and diabetes through hypertension, lipids, age and family history.

Correct Answer: Put them on before getting out of bed

Stockings go on first thing in the morning, before the legs become dependent and edema accumulates. A stocking pulled over an already swollen leg is harder to apply and delivers far less useful pressure. Option a is incorrect because walking makes the legs dependent and lets fluid collect in the tissues, so the stocking must then be forced over a swollen limb. The point of the morning rule is to beat that swelling. Option b is incorrect because a rolled or bunched top acts as a tourniquet at the thigh and obstructs the very drainage the garment is meant to improve. Wrinkles must be smoothed out instead. Option c is incorrect because stockings are normally removed at night unless a provider directs otherwise. Recumbency already drains the leg veins, so compression during sleep adds nothing and the skin needs a period without the garment.

Correct Answer: "I use a heating pad when my feet feel cold."

Heating pads are never used on the feet of a client with diabetes or arterial disease, because neuropathy prevents feeling a burn and heat raises demand in tissue already short of blood. Option a is incorrect because daily inspection of the feet is exactly what is taught, and a mirror or a helper is the recommended way to see the soles when the client cannot bend to look. Option b is incorrect because nails are meant to be cut straight across and filed at the edges; cutting down into the corners is what invites an ingrown nail and infection. Option d is incorrect because footwear indoors protects an insensate foot from unnoticed cuts and punctures, and never walking barefoot is the safety rule added to the course page by national diabetes guidance.

Correct Answer: The left subclavian vein

The thoracic duct drains both legs, the pelvis, the abdomen, the left thorax, the left arm and the left side of the head and neck, and it empties into the left subclavian vein. Option b is incorrect because the right lymphatic duct empties there, and it serves only the right head and neck, right arm, right thorax, right lung and pleura, right heart and right upper liver. Option c is incorrect because the superior vena cava carries venous blood from the upper body toward the heart and receives no lymphatic trunk directly. Lymph joins the circulation one step earlier, at the subclavian veins. Option d is incorrect because no lymphatic vessel opens into a cardiac chamber. Lymph must pass through nodes and then a duct before it is returned to venous blood well outside the heart itself.

Correct Answer: Come in today to be seen and treated

New redness, warmth, fever and a sudden increase in swelling in a lymphedematous limb suggest cellulitis, which needs prompt antibiotic treatment. Each infection destroys more lymphatic channels, so delay both worsens the infection and advances the lymphedema. Option a is incorrect because exercise and strength training are withheld while infection is present. Increasing activity in an inflamed limb can spread the infection and does nothing about the organism driving the redness and fever. Option c is incorrect because compression garments belong to the maintenance phase of decongestive therapy, not to an acute infection. Squeezing an actively infected limb can be painful and still leaves the cellulitis untreated. Option d is incorrect because a febrile spreading skin infection cannot wait a day for review. Cooling the surface may ease discomfort briefly while the underlying infection continues to spread through tissue that heals poorly.

Correct Answer: Intermittent claudication at two blocks of walking

Muscle pain brought on by walking and relieved by rest is intermittent claudication, and the number of blocks walked before pain begins is recorded as the claudication distance for later comparison. Option b is incorrect because rest pain occurs without any exercise, sits in the forefoot and toes, worsens lying flat and eases only when the limb hangs down; this client hurts only while walking. Option c is incorrect because venous pain is a heavy ache that builds with prolonged standing or sitting and is eased by putting the legs up, a pattern opposite to pain triggered by exertion. Option d is incorrect because restless legs syndrome causes an urge to move the legs at rest, mostly in the evening and at night, and it is not reproduced by a set walking distance.

Correct Answer: Chronic venous insufficiency of the leg

A shallow weepy ulcer at the medial malleolus with brown hemosiderin staining, a warm foot and a normal 2+ pulse is the venous picture; arterial inflow is intact, so perfusion signs stay normal. Option a is incorrect because arterial ulcers sit on the toes, metatarsal heads, heel or lateral malleolus in a cool limb with diminished or absent pulses, and they are dry and punched out rather than weeping. Option b is incorrect because lymphedema produces non-pitting brawny swelling that involves the dorsum of the foot and the toes with a positive Stemmer sign, and ulceration is uncommon unless the limb becomes infected. Option d is incorrect because deep vein thrombosis develops suddenly over hours to days with a red tense swollen tender calf, not with a chronic pigmented ulcer and years of skin change.