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

Left carotid artery bruit present; bruit heard in right carotid artery.

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

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

Answer and Explanation

The Correct Answer is B

Choice A rationale
The description of pulse volume (4+ and 0) is not appropriate for documenting a bruit. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, not pulse volume.
Choice B rationale
A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis. The presence of a bruit in the left carotid artery and the absence of sound in the right carotid artery should be documented as such.
Choice C rationale
While a bruit can indicate partial occlusion of an artery, it does not confirm complete occlusion. Complete occlusion would typically result in the absence of blood flow and no sound. Therefore, this choice is incorrect.
Choice D rationale
The presence of a bruit does not necessarily indicate a strong pulse. It indicates turbulent blood flow, which is often due to narrowing or partial blockage of the artery. This choice is incorrect

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

Explanation

Choice A rationale
Measuring skin elasticity around the ankles is not directly related to assessing the cause of cold feet. It is more relevant for assessing hydration status and skin turgor.
Choice B rationale
Assessing the volume of the pedal pulses is crucial to determine if there is adequate blood flow to the feet.
Choice C rationale
Palpating the dorsal surface of the feet for warmth helps assess the temperature and circulation to the feet.
Choice D rationale
Testing for a positive Babinski reflex is not relevant to assessing cold feet. It is used to assess neurological function.
Choice E rationale
Observing the color of the feet and toes helps assess circulation and potential issues such as cyanosis or pallor.

A. Place a mark where DP pulse is auscultated. B. Use a doppler to assess an audible DP pulse. C. Assess capillary refill distal to the DP pulse. D. Review client’s history for vascular disease.

Correct Answer is B

Explanation

Choice A rationale
Placing a mark where the DP pulse is auscultated can help in future assessments but does not address the immediate need to locate the pulse.
Choice B rationale
Using a Doppler to assess an audible DP pulse is the correct answer. A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable.
Choice C rationale
Assessing capillary refill distal to the DP pulse is important but should be done after attempting to locate the pulse with a Doppler.
Choice D rationale
Reviewing the client’s history for vascular disease is essential for understanding the underlying cause but does not address the immediate need to locate the pulse.

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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

An older male client reports to the nurse that his feet are cold. Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

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

Explanation

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Correct Answer is B

Explanation

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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?