A nurse is assessing the carotid arteries of a client diagnosed with cardiovascular disease. What action should be performed next by the nurse when assessing the carotid arteries in this client?

Demonstrate that both arteries will be palpated simultaneously to compare amplitude

Instruct the client take a deep breath and "hold" while the nurse briefly auscultates

Discuss that a light will be directed at the neck to observe for pulsations of the artery

Show the client the diaphragm of the stethoscope that will be placed on the neck

Answer and Explanation

The Correct Answer is B

A) Demonstrate that both arteries will be palpated simultaneously to compare amplitude: This is not recommended. Palpating both carotid arteries simultaneously can cause a decrease in blood flow to the brain, potentially leading to dizziness or syncope. It is important to palpate one carotid artery at a time to avoid reducing blood flow to the brain, especially in clients with cardiovascular disease or those at risk of stroke.

B) Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates: This is the correct approach. Instructing the client to hold their breath helps minimize any interference from respiratory sounds while auscultating the carotid arteries for bruits. This technique ensures that breath sounds do not mask any abnormal vascular sounds, such as bruits, which could indicate a blockage or narrowing of the carotid arteries.

C) Discuss that a light will be directed at the neck to observe for pulsations of the artery: Observing pulsations with light is not an appropriate technique for assessing the carotid arteries. Pulsations may be visible in some cases, but palpation and auscultation are the more reliable methods for evaluating the carotid arteries for abnormalities such as bruits or reduced pulse amplitude.

D) Show the client the diaphragm of the stethoscope that will be placed on the neck: While it is appropriate to explain the process to the client, the action of showing the stethoscope is unnecessary at this stage. The focus should be on instructing the client to hold their breath for proper auscultation to listen for any abnormal vascular sounds.

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Correct Answer is A

Explanation

A) The pupils constrict when the examiner's index finger slowly moves toward the client's nose: This is the correct description of the process of visual accommodation. Visual accommodation refers to the ability of the eyes to focus on a near object. When the examiner's finger is moved toward the client's nose, the pupils should constrict to focus the light on the retina. This response is an indicator that the client’s eyes are properly adjusting to focus on a close object.

B) The client's peripheral vision becomes sharper when the examiner shines a light over the pupils: This is not correct, as shining a light over the pupils is related to assessing the pupillary light reflex, not visual accommodation. Visual accommodation focuses on the ability to focus on a near object, while peripheral vision is related to the ability to see objects outside of the central vision, and is not influenced by the light shining directly into the pupil.

C) The pupils dilate when the examiner's finger slowly moves toward the client's nose: This is incorrect. When assessing visual accommodation, the pupils should constrict (become smaller) as the object moves closer to the face, not dilate. Dilation of the pupils would suggest a lack of accommodation and could indicate a neurological or eye condition.

D) The client involuntarily blinks in the presence of bright light directed at the pupils during the eye exam: This describes the corneal reflex, which is a response to bright light or a foreign object approaching the eye, rather than a test of visual accommodation. This reflex is mediated by the trigeminal nerve and is unrelated to the accommodation response, which focuses on the pupil's reaction to near objects.

A. II B. I C. VI D. IV

Correct Answer is A

Explanation

A) II:
This is the correct answer. The optic nerve (cranial nerve II) is responsible for visual acuity, as it transmits visual information from the retina to the brain. When assessing visual acuity, the nurse is evaluating the function of the optic nerve, which is responsible for the sense of vision. Therefore, cranial nerve II should be assessed during a visual acuity exam.

B) I:
This is incorrect. The olfactory nerve (cranial nerve I) is responsible for the sense of smell, not vision. Visual acuity is not related to the olfactory nerve, so it is not involved in this type of assessment.

C) VI:
This is incorrect. The abducens nerve (cranial nerve VI) controls the lateral rectus muscle of the eye, which is responsible for outward eye movement. While cranial nerve VI plays a role in eye movement, it is not directly involved in measuring visual acuity, which pertains to the function of the optic nerve.

D) IV:
This is incorrect. The trochlear nerve (cranial nerve IV) controls the superior oblique muscle, which helps with eye movement, specifically downward and inward eye movements. This nerve is not involved in measuring visual acuity.

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A nurse is assessing the carotid arteries of a client diagnosed with cardiovascular disease. What action should be performed next by the nurse when assessing the carotid arteries in this client?

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