The nurse is assessing the carotid arteries of a client with cardiovascular disease. What action should be performed next by the nurse?

Discuss that a light will be directed at the neck to observe for pulsations of the artery

instruct the client to take a deep breath and "hold" while the nurse briefly auscultates

Demonstrate that both arteries will be palpated simultaneously to compare amplitude

Show the client the diaphragm of the stethoscope that will be placed on the neck

Answer and Explanation

The Correct Answer is C

A. Discuss that a light will be directed at the neck to observe for pulsations of the artery:

This choice is incorrect. Directing light at the neck is not a standard method for assessing carotid artery pulsations. The carotid artery is usually assessed by palpation to feel the pulse rather than visual observation.

B. Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates:

This choice is incorrect. Auscultation is typically not used to assess carotid artery pulsations. Palpation (feeling the pulse) is the primary method used for this assessment.

C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude:

This choice is correct. Palpating both carotid arteries simultaneously allows the nurse to compare the amplitude (strength) of the pulses. This comparison helps in assessing the symmetry of the pulses and ensures there are no significant differences between the two sides, which could indicate vascular abnormalities.

D. Show the client the diaphragm of the stethoscope that will be placed on the neck:

This choice is incorrect. The diaphragm of the stethoscope is not typically used for palpating pulses. Palpation involves using the fingertips to feel the pulse and assess its strength and regularity.

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Correct Answer is C

Explanation

In this sequence:

Vena cava brings deoxygenated blood from the body into the right atrium.

Blood flows from the right atrium to the right ventricle through the tricuspid valve.

The right ventricle pumps blood into the pulmonary artery to the lungs.

In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.

From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.

The left ventricle then pumps oxygenated blood into the body through the aorta.

This sequence represents the systemic and pulmonary circulation of the heart.

A. A shiny, pearly white color tympanic membrane B. The presence of cerumen C. The presence of a cone of light D. A yellow or amber color to the tympanic membrane.

Correct Answer is D

Explanation

A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.

B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.

C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.

D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.

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The nurse is assessing the carotid arteries of a client with cardiovascular disease. What action should be performed next by the nurse?

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Naxlex Comprehensive Predictor Exams

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