A patient is presenting with a friction rub on auscultation. The nurse identifies that this
patient is most likely to have developed which of the following?
a. Atelectasis
b. Pneumonia
c. Pneumothorax
d. Pleural inflammation - ANSWER Pleural inflammation
The nurse is giving teaching to a new mother and is discussing safe handling of the
infant, including the vulnerability of the fontanels. The nurse states that the anterior
fontanel will close by about:
a. 18 months
b. 6 months
c. 8 months
d. 3 months - ANSWER 18 months
On examination of the client's respiratory status, the nurse locates the spot where the
manubrium and the body of the sternum come together. The above landmark is also
known as the:
a. Mid axillary line.
b. Intercostal space.
c. Xiphoid process.
d. Angle of Louis. - ANSWER Angle of Louis.
The nurse understands the importance of identifying the chest landmarks while
, performing a respiratory assessment as this aids in:
a. placing the patient for comfort
b. identifying the underlying lobes of the lung
c. proper placement of hands
d. maintaining safety of the patient - ANS identifying the underlying lobes of the lung
A goiter is an abnormal enlargement of the:
a. ears
b. nose
c. thyroid
d. tongue - ANS thyroid
Which vertebra is the prominent spinous process responsible for serving as a landmark
to locate other landmarks on the posterior thorax?
a. C7
b. T3
c. C1
d. C2 - ANWER C7
During assessment of a patients face, the nurse notes that the eyeballs appear to be
bulging and the upper eyelids are retracted. The nurse would chart this observation as
a. Cyanosis
b. Exophthalmos
c. Erythema
d. Normocephalic - ANSWER Exophthalmos
Percussion is only useful for detecting respiratory lesions that are superficial because it
only penetrates to a depth of:
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