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) Tricuspid and mitral: The tricuspid and mitral valves are best auscultated over the areas where the heart's valves are closest to the chest wall, specifically at the lower left sternal border and the apex, respectively. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of these valves.
B) Mitral and aortic: The mitral valve is auscultated at the apex, and the aortic valve is best heard at the 2nd intercostal space right sternal border. While a louder S2 may be associated with the aortic valve, it is not consistent with the mitral valve.
C) Aortic and pulmonic: The aortic valve and pulmonic valve are located in the areas where S2 (second heart sound) is predominantly heard. The aortic valve is located at the 2nd intercostal space right sternal border, and the pulmonic valve is heard at the 2nd intercostal space left sternal border. A louder S2 in the 2nd intercostal space right sternal border indicates a louder closure of the aortic valve and potentially the pulmonic valve as well.
D) Pulmonic and tricuspid: The pulmonic valve is auscultated at the 2nd intercostal space left sternal border, while the tricuspid valve is heard best at the lower left sternal border. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of the tricuspid valve.

A. Assist the client to a standing position. B. Focus a penlight on the client's chest. C. Use tangential lighting D. Use perpendicular lighting.

Correct Answer is C

Explanation

A. Assist the client to a standing position: While positioning can be important for various assessments, inspecting the apical impulse is best done with the client in a supine or left lateral position. Standing may not provide the best view or palpation for the apical impulse, which is usually assessed more accurately in a different position.

B. Focus a penlight on the client's chest: A penlight alone may not provide sufficient illumination for detailed inspection of the apical impulse. It is more important to use appropriate lighting techniques to ensure a clear view of the heart's movements.

C. Use tangential lighting: Tangential lighting is particularly useful for inspecting and palpating the apical impulse because it casts light across the surface, highlighting contours and movements. This type of lighting helps the nurse visualize the apical impulse more clearly by creating shadows that accentuate the impulse's presence and movements.

D. Use perpendicular lighting: Perpendicular lighting might not be as effective in highlighting the subtle movements of the apical impulse. Tangential lighting is preferred because it creates shadows and contrasts that make the apical impulse more visible and easier to assess.

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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 auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves?

Correct Answer is C

Explanation

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Correct Answer is C

Explanation

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