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Practice qUESTIONS| WITH COMPLETE SOLUTIONS GRADED A+ ALEADY VERIFIED In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse $10.99
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Practice qUESTIONS| WITH COMPLETE SOLUTIONS GRADED A+ ALEADY VERIFIED In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse
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Practice qUESTIONS| WITH COMPLETE SOLUTIONS GRADED A+ ALEADY VERIFIED In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal...

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HESI Prep - Health Assessment
Practice qUESTIONS| WITH
COMPLETE SOLUTIONS GRADED A+
ALEADY VERIFIED



In an interview, the nurse may find it necessary to take notes to aid his or her
memory later. Which statement is true regarding note-taking?



A) Note-taking may impede the nurse's observation of the patient's nonverbal
behaviors.

B) Note-taking allows the patient to continue at his or her own pace as the nurse
records what is said.

C) Note-taking allows the nurse to shift attention away from the patient, resulting
in an increased comfort level.

D) Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort. - Ans>>A) Note-taking may impede the
nurse's observation of the patient's nonverbal behaviors.



Some use of history forms and note-taking may be unavoidable. But be aware
that note-taking during the interview has disadvantages. It breaks eye contact too
often, and it shifts attention away from the patient, which diminishes his or her

,sense of importance. It also may interrupt the patient's narrative flow, and it
impedes the observation of the patient's nonverbal behavior.



Pathologic conditions that increase lung density, such as pulmonary consolidation,
will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.



The nurse is listening to the breath sounds of a patient with severe asthma. Air
passing through narrowed bronchioles would produce which of these
adventitious sounds?



A) Wheezes

B) Bronchial sounds

C) Bronchophony

D) Whispered pectoriloquy - Ans>>A) Wheezes



Wheezes are caused by air squeezed or compressed through passageways
narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as
with acute asthma or chronic emphysema.



An adult patient with a history of allergies comes to the clinic complaining of
wheezing and difficulty in breathing when working in his yard. The assessment

,findings include tachypnea, use of accessory neck muscles, prolonged expiration,
intercostal retractions, decreased breath sounds, and expiratory wheezes. The
nurse interprets that these assessment findings are consistent with:



A) asthma.

B) atelectasis.

C) lobar pneumonia.

D) heart failure. - Ans>>A) asthma.



Asthma is allergic hypersensitivity to certain inhaled particles that produces
inflammation and a reaction of bronchospasm, which increases airway resistance,
especially during expiration. Increased respiratory rate, use of accessory muscles,
retraction of intercostal muscles, prolonged expiration, decreased breath sounds,
and expiratory wheezing are all characteristic of asthma. See Table 18-8 for
descriptions of the other conditions.



During auscultation of breath sounds, the nurse should use the stethoscope
correctly, in which of the following ways?



A) Listen to at least one full respiration in each location.

B) Listen as the patient inhales and then go to the next site during exhalation.

, C) Have the patient breathe in and out rapidly while the nurse listens to the
breath sounds.

D) If the patient is modest, listen to sounds over his or her clothing or hospital
gown. - Ans>>A) Listen to at least one full respiration in each location.



During auscultation of breath sounds with a stethoscope, it is important to listen
to one full respiration in each location. During the examination, the nurse should
monitor the breathing and offer times for the person to breathe normally to
prevent possible dizziness.



During palpation of the anterior chest wall, the nurse notices a coarse, crackling
sensation over the skin surface. On the basis of these findings, the nurse suspects:



A) tactile fremitus.

B) crepitus.

C) friction rub.

D) adventitious sounds. - Ans>>B) crepitus.



Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in
subcutaneous emphysema when air escapes from the lung and enters the
subcutaneous tissue, as after open thoracic injury or surgery.

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