A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

to check radial pulses

to assess pedal pulses

to assess jugular filling pressure

to auscultate lung sounds

Answer and Explanation

The Correct Answer is C

A) To check radial pulses: Radial pulses are typically assessed by palpation at the wrist. A gooseneck lamp is not necessary for this task; standard lighting and direct palpation are usually sufficient.
B) To assess pedal pulses: Pedal pulses are assessed by palpation on the top of the foot. A gooseneck lamp is not needed for this purpose, as the lighting conditions are generally adequate for palpation in a well-lit room.
C) To assess jugular filling pressure: Assessing jugular venous pressure (JVP) requires good lighting to clearly see the pulsations in the jugular veins. A gooseneck lamp provides focused and adjustable lighting, which is helpful for this assessment. This ensures accurate observation of the jugular veins and helps in evaluating the severity of heart failure.
D) To auscultate lung sounds: Auscultating lung sounds involves using a stethoscope and does not typically require a gooseneck lamp. Proper lighting is not essential for auscultation, as the focus is on auditory assessment rather than visual inspection.

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Correct Answer is C

Explanation

A. Stiffening of the large arteries: Stiffening of the large arteries is a common age-related change and can contribute to increased systolic blood pressure. While this change can affect cardiovascular function, it does not directly increase the risk of falls as much as other factors.
B. Rise in the systolic blood pressure: An increase in systolic blood pressure often occurs with aging due to arterial stiffening. Elevated systolic blood pressure alone does not directly cause an increased risk of falls but is a part of the broader spectrum of cardiovascular changes.
C. Postural orthostatic hypotension: Postural orthostatic hypotension (OH) is characterized by a significant drop in blood pressure when a person stands up from a sitting or lying position, leading to dizziness or lightheadedness. This condition is common in older adults and significantly increases the risk of falls, as it can cause sudden dizziness and unsteadiness upon standing.
D. Decline of pacemaker cells in the sino-atrial node: The decline of pacemaker cells in the sinoatrial node can lead to bradycardia or irregular heart rhythms, which are related to cardiac function. While this can affect overall cardiovascular health, it does not directly contribute to the risk of falls as much as the sudden changes in blood pressure associated with postural orthostatic hypotension.

A. Keep the pace of the history moving forward to reduce time. B. Limit the use of brief screening tools C. Limit open-ended questions. D. Have the room well-lit with minimal background noise.

Correct Answer is D

Explanation

(A) Keep the pace of the history moving forward to reduce time: While it's important to be efficient, rushing through the health history can compromise the quality of the information gathered. Older adults may need more time to recall details and respond thoughtfully. Ensuring a thorough and patient approach is essential for obtaining accurate and comprehensive information.
(B) Limit the use of brief screening tools: Brief screening tools can be valuable for identifying specific health issues quickly and efficiently. Limiting their use might lead to missing important information or failing to detect underlying conditions. Using appropriate screening tools helps in capturing relevant data and providing a better overall assessment.
(C) Limit open-ended questions: Open-ended questions are crucial in obtaining detailed and descriptive responses from older adults. Limiting their use could hinder the ability to understand the client’s complete health history and concerns. These questions encourage clients to elaborate on their experiences and provide more nuanced information.
(D) Have the room well-lit with minimal background noise: A well-lit room with minimal background noise creates an environment conducive to effective communication. Older adults might have impaired vision or hearing, so ensuring good lighting and reducing distractions helps them focus and respond more accurately. This strategy enhances the accuracy of the health history and facilitates better interaction between the nurse and client.

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A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

Correct Answer is C

Explanation

Which strategy can the nurse use to effectively approach the older adult client during the health history?

Correct Answer is D

Explanation

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