The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Listen to the heart sounds using the bell of a stethoscope.

Use a Doppler ultrasound to hear the heartbeat.

Obtain a pulse oximeter reading from two extremities.

Auscultate for one minute with the stethoscope's diaphragm.

Answer and Explanation

The Correct Answer is A

A.   The bell of the stethoscope is best for detecting low-pitched sounds like murmurs or extra heart sounds.
B.   A Doppler ultrasound is not necessary for routine auscultation of heart sounds.
C.   Pulse oximetry does not provide relevant information about heart sounds.
D.   Auscultating with the diaphragm is better for high-pitched sounds, so the bell is preferred for extra heart sounds.

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Correct Answer is D

Explanation

A. Observing pupillary response to a penlight helps assess the neurological function related to the eyes, such as reaction to light, but it does not directly assess the client's overall visual acuity or support the claim of being legally blind.
B. Examining the optic disc can help identify structural changes in the eye, such as damage to the retina or optic nerve, but it doesn't directly assess the client’s claim of being legally blind or the extent of visual impairment.
C. Assessing eye movements can help evaluate for conditions such as strabismus or cranial nerve abnormalities, but it doesn't provide a direct assessment of visual acuity or support the client’s statement of blindness.
D. The Snellen chart is a standard tool for assessing visual acuity and is the most appropriate method to objectively measure whether the client has the visual impairment consistent with being legally blind.

A. Sudden onset of severe anxiety, fear, and concern. B. Periumbilical pain localizing to right lower quadrant. C. Diffuse abdominal pain with elevated neutrophil count. D. Anorexia progressing to nausea, vomiting, and fever.

Correct Answer is B

Explanation

A. While anxiety and fear can accompany many medical conditions, they are not typically associated with appendicitis. Appendicitis is characterized by physical symptoms like pain and digestive disturbances rather than emotional symptoms.
B. Periumbilical pain that shifts to the right lower quadrant is the classic presentation of appendicitis. As the inflammation progresses, pain tends to move from the mid-abdomen to the lower right abdomen, which supports a diagnosis of appendicitis.
C. Diffuse abdominal pain is less specific and could indicate a variety of conditions. While an elevated neutrophil count can suggest infection or inflammation, the localized pain seen in appendicitis is a more distinguishing feature.
D. These symptoms are also common in appendicitis, as it typically presents with loss of appetite, nausea, and fever. However, the hallmark symptom is localized pain, particularly in the right lower quadrant, making B a stronger indication.

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The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

Correct Answer is D

Explanation

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Correct Answer is B

Explanation

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