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: Hyperthyroidism may cause eye issues like exophthalmos, not cataracts. Lens opacity from aging or smoking outweighs thyroid risk, making this 55-year-old less prioritized for cataract screening than older, smoking-exposed clients in this context fully.
Choice B reason: Minimal alcohol (two beers weekly) at 30 poses no cataract risk. Age and smoking are stronger factors; this young client lacks the cumulative exposure or oxidative stress tied to lens clouding, excluding them entirely here.
Choice C reason: At 75, with 50 years of smoking, this client faces high cataract risk. Aging degrades lens proteins, and smoking’s oxidative damage accelerates opacity, making this the priority for assessment and education on cataract prevention accurately here.
Choice D reason: Arteriosclerosis at 40 affects vessels, not lenses directly. While vascular health matters, age and smoking outweigh this risk for cataracts, rendering this client lower priority than the older, heavily smoking individual in this scenario fully.

A. Cerebral stagger B. Scissors gait C. Parkinsonian gait D. Cerebellar ataxia

Correct Answer is D

Explanation

Choice A reason: Cerebral stagger isn’t a standard term; cerebral damage might cause spasticity, not wide-based ataxia. This lacks specificity for cerebellar signs like staggering, misaligning with the broad, unsteady gait tied to coordination loss in this client fully.
Choice B reason: Scissors gait, from cerebral palsy, shows stiff, crossed legs, not wide-based staggering. This spastic pattern contrasts with the unsteady, broad stance of cerebellar dysfunction, excluding it as the correct description for this presentation entirely here.
Choice C reason: Parkinsonian gait is shuffling with small steps and rigidity, not wide-based or staggering. This contrasts with the unsteady, broad stance of cerebellar ataxia, making it an incorrect match for the client’s observed walking pattern fully here.
Choice D reason: Cerebellar ataxia causes a wide-based, staggering gait due to coordination loss from cerebellar damage. This matches the client’s unsteady walk, reflecting impaired balance and motor control, accurately describing the observed gait pattern comprehensively here.

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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

A client with a wide-based, staggering, unsteady gait walks into the clinic. The gait would be correctly described as which of the following?

Correct Answer is D

Explanation

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