The nurse is completing an assessment on a client suspected of having a transient ischemic attack. Which of the following techniques should the nurse use to assess the client's carotid arteries?

Simultaneously palpating both arteries to compare amplitude.

Listening with the diaphragm of the stethoscope to assess for bruits.

instructing the patient to take slow deep breaths during auscultation.

Palpating the artery at the base of the neck of the neck.

Answer and Explanation

The Correct Answer is B

A. Simultaneously palpating both arteries to compare amplitude: While comparing amplitudes is important, using the diaphragm of the stethoscope to listen for bruits (abnormal whooshing sounds indicating turbulent blood flow) is a more specific and accurate method for assessing the carotid arteries for potential vascular issues.

B. Listening with the diaphragm of the stethoscope to assess for bruits: This technique allows the nurse to detect abnormal sounds (bruits) that could indicate partial blockages or stenosis in the carotid arteries, suggesting a risk of stroke or transient ischemic attack.

C. Instructing the patient to take slow deep breaths during auscultation: Deep breaths are more relevant during lung auscultation. Carotid artery assessment focuses on detecting abnormal sounds and assessing blood flow rather than respiratory patterns.

D. Palpating the artery at the base of the neck: Palpation alone does not provide enough information about potential blockages or abnormalities in the carotid arteries. Listening with a stethoscope allows for a more detailed assessment of blood flow and the presence of bruits. f the nurse hears a bruit during auscultation, they should not palpate the carotid artery. A bruit suggests partial obstruction (carotid stenosis), and compressing the artery further could worsen blood flow.

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Correct Answer is D

Explanation

A. Clear and equal breath sounds bilaterally

Explanation: Clear and equal breath sounds bilaterally indicate normal lung sounds, suggesting proper air exchange in both lungs. This is a normal finding and does not require immediate reporting.

B. Oxygen saturation of 98% on room air

Explanation: An oxygen saturation level of 98% on room air indicates adequate oxygenation of the blood. This is a normal and healthy oxygen saturation level and does not require immediate reporting.

C. Cough producing clear, thin sputum

Explanation: A cough producing clear, thin sputum is indicative of a non-infected or non-inflammatory condition in the respiratory system. Clear and thin sputum is often normal, especially in the absence of other symptoms. It does not require immediate reporting unless the client has other concerning symptoms.

D. Visible use of accessory muscles during inhalation

Explanation: Visible use of accessory muscles, such as neck or intercostal muscles, during inhalation suggests that the client is working hard to breathe. This could indicate respiratory distress, potentially due to conditions like asthma, COPD (Chronic Obstructive Pulmonary Disease), or other severe lung problems. It's a concerning sign and should be reported to the healthcare practitioner promptly for further evaluation and intervention.

A. Inform the client that his breast enlargement is benign, and normal for a man of his age B. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. C. Recommend that he alter his diet to include fewer fats and more lean proteins D. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

Correct Answer is B

Explanation

A. Inform the client that his breast enlargement is benign, and normal for a man of his age:

This choice is not appropriate because while gynecomastia can be benign, it should not be assumed without a proper medical evaluation. Gynecomastia can have various causes, including hormonal imbalances or underlying medical conditions. It's crucial to identify the cause through a medical assessment.

B. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician:

This is the correct choice. Gynecomastia can indeed be caused by hormonal changes, but it can also be due to medications, certain health conditions, or hormonal imbalances. Therefore, the nurse should recommend a medical evaluation to determine the underlying cause and appropriate management.

C. Recommend that he alter his diet to include fewer fats and more lean proteins:

This choice is not relevant to gynecomastia. Gynecomastia is not typically caused by dietary factors, so altering the diet would not be a suitable response to this situation.

D. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened:

This choice is incorrect. Gynecomastia is not directly associated with prostate enlargement. While both conditions can occur in older men, they are distinct medical issues. Screening for prostate enlargement is not indicated based solely on the presence of gynecomastia. Proper evaluation and assessment of each condition are necessary.

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The nurse is completing an assessment on a client suspected of having a transient ischemic attack. Which of the following techniques should the nurse use to assess the client's carotid arteries?

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