In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Left carotid artery has strong pulse; right carotid artery occluded.

Left carotid pulse volume of 4+; right carotid pulse volume of 0.

Left carotid artery occlusion present; no occlusion of right carotid artery.

Left carotid artery bruit present; no bruit heard in right carotid artery.

Answer and Explanation

The Correct Answer is D

A) Left carotid artery has strong pulse; right carotid artery occluded:
This documentation is incorrect because the presence of a bruit does not indicate a strong pulse or occlusion. A bruit suggests turbulent blood flow, often due to partial obstruction or narrowing of the artery, not necessarily a strong pulse or complete occlusion.

B) Left carotid pulse volume of 4+; right carotid pulse volume of 0:
This documentation focuses on the pulse volume rather than the presence of a bruit. The nurse's assessment was related to auscultation findings (bruit) rather than palpation findings (pulse volume).

C) Left carotid artery occlusion present; no occlusion of right carotid artery:
A bruit indicates turbulent blood flow, which may be due to partial obstruction, but it does not confirm complete occlusion. Therefore, this documentation would be inaccurate.

D) Left carotid artery bruit present; no bruit heard in right carotid artery:
This documentation accurately reflects the nurse's findings. A bruit is a blowing, swishing sound indicating turbulent blood flow, often due to narrowing or partial obstruction of the artery. Documenting the presence of a bruit provides essential information for further evaluation and management.

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Correct Answer is C

Explanation

A) Ask about recent abdominal trauma:
While abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen. Additionally, without further evidence or symptoms suggestive of trauma, it may not be necessary to immediately inquire about recent abdominal trauma.

B) Observe the midline for scarring:
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions. However, the presence of a depressed umbilicus below the surface of the abdomen does not necessarily indicate scarring or previous surgery.

C) Document the normal finding:
A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.

D) Palpate the area for masses:
Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation. In the absence of other concerning findings, it may be unnecessary and potentially uncomfortable for the client to perform palpation based solely on the observation of a depressed umbilicus.

A. Notify the healthcare provider of the rebound tenderness. B. Obtain a prescription to catheterize the client's bladder. C. Offer to administer a laxative prescribed for PRN use. D. Instruct the client in distraction and relaxation techniques.

Correct Answer is A

Explanation

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

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In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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