The instructor asks the student nurse to auscultate the client's Erb's Point.
Where is the cardiac landmark referred to as the Erb's Point located?
5th ICS Left MCL.
3rd ICS Left SB.
2nd ICS Left SB.
4th ICS Left SB.
The Correct Answer is B
Choice A rationale
5th ICS Left MCL is the location for the apical impulse (point of maximal impulse), not Erb's Point.
Choice B rationale
Erb's Point is located at the 3rd ICS Left SB and is significant for auscultation of heart sounds, particularly the S1 and S2 sounds.
Choice C rationale
2nd ICS Left SB is the location for auscultating the pulmonic valve area.
Choice D rationale
4th ICS Left SB is where the tricuspid valve is auscultated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Lordosis refers to an excessive inward curvature of the lumbar spine, often referred to as swayback. This condition causes the lower back to arch more than normal, leading to a prominent abdomen and buttocks. Lordosis does not affect the thoracic spine and does not cause an exaggerated curvature in that region.
Choice B rationale
Scoliosis is a lateral curvature of the spine that results in an S- or C-shaped curve. It can occur in the thoracic, lumbar, or cervical regions of the spine. Scoliosis involves a sideways deviation rather than an exaggerated curvature in the thoracic spine.
Choice C rationale
Spinal dysplasia is a broad term that refers to various congenital abnormalities affecting the development of the spine. It includes conditions such as spina bifida, kyphosis, and scoliosis, each with distinct characteristics. The term itself does not specify an exaggerated thoracic curvature.
Choice D rationale
Kyphosis is an exaggerated outward curvature of the thoracic spine, resulting in a rounded or hunched back appearance. This condition is common in elderly individuals and can be caused by factors such as osteoporosis, vertebral fractures, or degenerative changes. It leads to a noticeable forward bend of the upper back.
Correct Answer is A
Explanation
Choice A rationale
The sides of the mouth being symmetric when the patient smiles indicate intact function of the facial cranial nerve (CN VII). This nerve controls the muscles responsible for facial expressions, including smiling, frowning, and closing the eyes. Symmetry in these actions suggests that the facial nerve is functioning properly and that there is no nerve damage or weakness.
Choice B rationale
The patient's eyes moving to the left, right, up, down, and obliquely during conversation are functions of the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI), not the facial cranial nerve (CN VII). These nerves work together to control the movements of the eye muscles, enabling the eyes to move in different directions and maintain proper alignment.
Choice C rationale
Periodic blinking of the eyelids involves the oculomotor nerve (CN III) and the facial nerve (CN VII). The oculomotor nerve controls the muscles that lift the eyelid, while the facial nerve controls the muscles that close the eyelid. Blinking is a coordinated action involving both nerves, but the observation alone is not sufficient to determine the integrity of CN VII.
Choice D rationale
The patient moistening the lips with the tongue involves the function of the hypoglossal nerve (CN XII), which controls the movements of the tongue. The hypoglossal nerve is responsible for the motor control of most of the tongue muscles, allowing for actions like licking the lips, speaking, and swallowing. It is not related to the facial cranial nerve (CN VII).
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