Question

51. The nurse notes a murmur on auscultation of the heart what sound would the nurs have noted during the examination? A. A raspy machine like a blowing sound B. An extra beat just before the S2 heart sound C.A prominent S1 sound in the aortic and pulmonic D. An S4 gallop e areas 52. Why would the nurse use the bell of the stethoscope when listening to the abdomen? A. To better hear bowel sounds B. To assess fora Bruit C. To assess for organomegaly D. To assess for bladder sound 53. When inspecting a client's posterior wall of the pharynx and tonsils the nurse notes4+ tonsils what did the nurse observe? A. Both tonsils have a glistening texture B. Left and right tonsils almost touch the uvula C. Left and right tonsils extend just beyond the posterior pillars D. Tonsils are touching each other 54. What does thoracic expansion assess? A. Chest movement B. Breath sound C. Vibration D. Voice sounds 55. The nurse assesses an apical heart rate and notes a bradycardia what was the epical heart rate? A. Greater than 100 beats per minute B. Greater than 150 beats per minute C. Less than 60 beats per minute D. 60-90 beats per minute

Answer 1

51. Heart sound consist of normal heart sound (S1 S2), abnormal heart sound or gallops (S3, S4) and murmurs. Murmurs are caused due to forceful turbulent flow of blood within the heart due to heart defects so strong that it can be auscultated.

51. A.

52.Stethoscope has two sides ie. The bell and the diaphragm. The diaphragm is generally used to hear the high pitched sound ie. Heart sounds and lung sounds whereas bell is used to hear low pitch sound like murmur in heart or bruit in abdomen.

52. B

53. Tonsils get enlarged on being inflammed to varying severity. They vary in presentation starting from hidden within the tonsillar pillar to tonsils going beyond midline and touching each other. Grade 1- tonsil within pillars, grade 2- tonsils extending to pillars grade 3- tonsils beyond pillars and grade 4- tonsils extend midline and touch each other.

53-D

54. Thoracic expansion mainly measures the lung expansion. It is the measurement taken at the end of the deep inspiration and expiration. It assesses chest movement

54-A

55. Heart rates or Pulse can be assessed in various sites mainly including the radial, brachial, femoral, carotid, apical etc. The site apical is assesses at 5th intercostal space mid clavicular line on left side of chest which is considered to be placement of apex of heart. Bradycardia is pulse rate at 60 beats/min or below.

55-C