health assessment exam 2 test bank

Correct Answer: B

Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination. Incorrect Answers: A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention. C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion. D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.

Correct Answer: D

Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.

Correct Answer: B

Rationale: The correct answer is B: Cold, dry air. Cold, dry air is a common trigger for asthma exacerbations, as it can irritate the airways and lead to bronchoconstriction. This trigger can worsen asthma symptoms and increase the risk of an asthma attack. Educating the patient to avoid cold, dry air can help prevent asthma flare-ups. Explanation for why the other choices are incorrect: A: Exercise-induced asthma is triggered by physical activity but can be managed with proper warm-up and medication. It is not typically something to avoid altogether. C: Caffeine is a mild bronchodilator and can actually help alleviate asthma symptoms in some cases. D: Environmental allergens can trigger asthma in some individuals, but they vary from person to person, so avoidance strategies would depend on specific allergens identified through testing.

Correct Answer: D

Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.

Correct Answer: B

Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.