The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

The jugular venous pulse is visible when the client lies supine.

The jugular veins are distended when the client sits at a 45-degree angle.

The jugular venous pulse is not visible when the client is sitting upright.

The jugular veins are fully distended when the client is in a high Fowler position.

Answer and Explanation

The Correct Answer is C

Choice A reason: Visible jugular pulse supine is normal, as gravity pools venous blood. However, the question seeks upright findings. This is expected lying down, not sitting, misaligning with the healthy standard for an upright position in this context fully.

Choice B reason: Distended jugular veins at 45 degrees suggest elevated central venous pressure, like in heart failure, not health. In a healthy client, veins collapse at this angle, making this an abnormal, not expected, finding for jugular assessment here.

Choice C reason: No visible jugular pulse upright is normal in health, as venous pressure drops below the clavicle when sitting. This reflects proper heart function and gravity’s effect, aligning with expected findings in a healthy client’s neck vessel exam accurately.

Choice D reason: Full jugular distension in high Fowler’s (60-90 degrees) indicates pathology, like right heart failure, not health. Healthy veins collapse at this elevation, making this an abnormal finding, not the expected norm for jugular assessment entirely here.

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Correct Answer is C

Explanation

Choice A reason: The base of the skull houses occipital nodes, not submental ones, which drain the lower face. Palpating here misses the submental region, irrelevant to sinus or throat infections, misaligning with lymphatic drainage patterns in this case.

Choice B reason: The angle of the jaw targets submandibular nodes, not submental, which sit midline under the chin. This area drains the jaw and mouth but not specifically the submental zone tied to the client’s symptoms directly.

Choice C reason: Behind the chin tip is the submental node location, draining the lower lip, tongue, and anterior mouth. With sinus and throat infection, this spot is key for detecting lymphadenopathy linked to the client’s fever and elevated WBC.

Choice D reason: Behind the ears assesses postauricular nodes, unrelated to submental drainage of the chin and mouth. This misses the infection’s likely lymphatic response, focusing on a region not typically involved in sinus or throat pathology here.

A. Rapid oscillations of the ankle B. Deviation of the heel to one side C. Pain and flexion in the knee D. The client reports paresthesia

Correct Answer is B

Explanation

Choice A reason: Rapid ankle oscillations might suggest tremor, possibly basal ganglia issues, not cerebellar dysfunction. The heel-shin test assesses coordination, where cerebellar damage causes drift, not rhythmic shaking, making this less indicative of the target pathology here.
Choice B reason: Heel deviation to one side in the heel-shin test signals cerebellar dysfunction, impairing coordination. The cerebellum fine-tunes movement; damage causes ataxia, leading to inaccurate sliding, making this the key sign of cerebellar issues accurately.
Choice C reason: Pain and knee flexion suggest joint or nerve issues, not cerebellar dysfunction. This test evaluates smooth motion, not pain response; cerebellar problems show ataxia, not discomfort, disconnecting this from the intended motor assessment fully.
Choice D reason: Paresthesia (tingling) indicates sensory nerve issues, not cerebellar motor control. The cerebellum coordinates movement, not sensation; this response misses the coordination focus of the heel-shin test, excluding it as a cerebellar sign here entirely.

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The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is testing for motor functioning by having the client lie down and slide the heel of the right foot down the left shin and then slide the heel of the left foot down the right shin. Which response by the patient would indicate that there may be cerebellar dysfunction?

Correct Answer is B

Explanation

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