A nurse is completing an assessment o a client suspected of having a carotid artery blockage. Which of the following techniques should the nurse to assess the client's carotid arteries?

Simultaneously palpating both arteries to compare amplitude

Auscultating the artery at the base of the neck at the carotid bifurcation

Listening with the diaphragm of the stethoscope to assess for bruits

Instructing the client to take deep breaths during auscultation

Answer and Explanation

The Correct Answer is B

A) Simultaneously palpating both arteries to compare amplitude: Palpating both carotid arteries simultaneously is contraindicated as it can obstruct blood flow to the brain, potentially causing a decrease in cerebral perfusion and leading to syncope or other complications. Each artery should be palpated one at a time to prevent this risk.

B) Auscultating the artery at the base of the neck at the carotid bifurcation: The correct technique for assessing for carotid artery blockage is to auscultate the artery at the carotid bifurcation, which is located at the base of the neck. The nurse should use the bell of the stethoscope to listen for bruits, which are abnormal sounds caused by turbulent blood flow due to narrowing or blockage of the artery. This is a non-invasive method used to detect vascular abnormalities.

C) Listening with the diaphragm of the stethoscope to assess for bruits: The diaphragm of the stethoscope is generally used for high-pitched sounds like lung and bowel sounds. For auscultating bruits, the bell of the stethoscope is preferred because it is more sensitive to low-pitched sounds, which are characteristic of bruits caused by turbulent blood flow in narrowed arteries.

D) Instructing the client to take deep breaths during auscultation: Instructing the client to take deep breaths is unnecessary and could alter the sound being auscultated. The nurse should have the client breathe normally to avoid interference with the auscultation of the carotid arteries. The goal is to listen for any abnormal sounds (bruits) without any external factors affecting the findings.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A) Daily, during the shower or bath:
This is incorrect. Performing a breast self-examination (BSE) daily is not necessary. The goal of BSE is to check for any changes over time, not to examine the breasts every day. It's more effective to perform the exam regularly at a consistent time each month.

B) One week after the menstrual period:
This is incorrect. This instruction is relevant for pre-menopausal women, where the hormonal changes associated with the menstrual cycle can cause breast tissue to feel lumpy or swollen. The best time for them to perform a BSE is one week after the menstrual period ends when the breasts are least likely to be swollen or tender. However, for postmenopausal women, this is not necessary, as their hormonal levels are stable throughout the month.

C) On the same day every month:
This is the correct answer. For postmenopausal women, who no longer have menstrual cycles, the best time to perform a breast self-exam is on the same day every month. This ensures consistency and makes it easier for the client to notice any changes in the breast tissue over time. The day chosen should be one that is convenient and easy to remember, and it does not matter whether it is during the shower or bath, as long as the examination is done regularly.

D) Weekly, at the client's convenience:
This is incorrect. While performing a BSE weekly is not necessary, the key is consistency rather than frequency. Performing the exam monthly is sufficient, and it should be on a specific day each month, rather than at the client’s convenience on an irregular basis.

A. Client's oral temperature is 38.40 C (101.2° F). B. Client reports the rash on their back is itchy. C. Client reports nausea following, administration of pain medication. D. Client has a vesicular rash on their upper back. E. Client reports dull, aching pain in lower right call.

Correct Answer is ["B","C","E"]

Explanation

A) Client's oral temperature is 38.4°C (101.2°F):
This is objective data, as it is a measurable, observable finding obtained through direct assessment (in this case, using a thermometer). Objective data are facts or measurements that can be verified or observed by the healthcare provider.

B) Client reports the rash on their back is itchy:
This is subjective data, as it is based on the client's personal experience and report. The feeling of itchiness cannot be directly measured or observed by the nurse; it is something the client experiences and describes. Subjective data include symptoms, sensations, or feelings reported by the client.

C) Client reports nausea following administration of pain medication:
This is subjective data. Nausea is a symptom that the client reports experiencing, which cannot be objectively measured or directly observed by the nurse. It is based on the client's perception and report, making it subjective.

D) Client has a vesicular rash on their upper back:
This is objective data. The rash is something the nurse can observe and describe. Objective data include observable facts, such as physical exam findings, lab results, or diagnostic test results.

E) Client reports dull, aching pain in lower right calf:
This is subjective data, as pain is a sensation that the client experiences and describes. The intensity, location, and type of pain (dull, aching) are subjective experiences that only the client can report.

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A nurse is completing an assessment o a client suspected of having a carotid artery blockage. Which of the following techniques should the nurse to assess the client's carotid arteries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?

Correct Answer is C

Explanation

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client complaining of throbbing pain in the face, teeth, and cheeks. Upon palpation, the nurse notes swollen turbinates and a purulent discharge the nose. The nurse should recognize that the client's symptoms best correlate with which problem?

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A nurse is auscultating the lungs of a client and hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. How should the nurse interpret these findings?

A client was recently diagnosed with a heart murmur and is asking the nurse for more information. How should the nurse describe to the client about what a heart murmur is?

A nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from these findings?

A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?

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