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 A

Explanation

A) Continue with the remainder of the client's physical assessment:
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, there is no immediate concern or need for further action related to this finding. The nurse should continue with the remainder of the client's physical assessment.

B) Report the client's abnormal lung sounds to the healthcare provider:
Vesicular breath sounds are considered normal lung sounds and do not warrant reporting as abnormal. Reporting this finding to the healthcare provider would not be appropriate and may lead to unnecessary concern or intervention.

C) Ask the client to cough and then auscultate at the site again:
Coughing would not be necessary in response to hearing vesicular breath sounds, as these are normal lung sounds. Repeating the auscultation may not provide additional information beyond confirming the presence of normal breath sounds.

D) Measure the client's oxygen saturation with a pulse oximeter:
Measuring oxygen saturation with a pulse oximeter is not indicated in response to hearing vesicular breath sounds. These breath sounds are normal and do not necessarily indicate a problem with oxygenation. Therefore, measuring oxygen saturation would not be the appropriate action in this situation.

A. been sleeping well?" B. been depressed lately?" C. had anything to eat in the last 24 hours?" D. ever had problems with your blood sugar?" E. None F. None

Correct Answer is A

Explanation

Answer: A. "Have you been sleeping well?"

Rationale:

A) "Have you been sleeping well?": Sleep deprivation can lead to symptoms such as an expressionless facial affect, slurred speech, and red conjunctivae. Assessing for sleep patterns is a priority to rule out this common and reversible cause of the client's symptoms. Sleep deprivation can also exacerbate other underlying conditions.

B) "Have you been depressed lately?": While depression could explain the expressionless affect, it does not typically cause slurred speech or red conjunctivae. Depression can be assessed later if other immediate causes are ruled out.

C) "Have you had anything to eat in the last 24 hours?": Poor nutritional intake could contribute to fatigue or weakness but is less likely to cause all the observed symptoms (expressionless affect, slurred speech, and red conjunctivae). This question is important but not the first priority.

D) "Have you ever had problems with your blood sugar?": Blood sugar imbalances, particularly hypoglycemia or hyperglycemia, can cause neurological changes. However, the symptoms described are less specific to blood sugar issues and more indicative of sleep or neurological concerns, making this question less immediately relevant.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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