The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

S1 and S2 heard with diaphragm of stethoscope

A blowing sound heard over the mitral area with the bell of the stethoscope

Apical pulse palpated at 5th intercostal space, midclavicular line

Absent sound over carotid arteries with bell of the stethoscope

Answer and Explanation

The Correct Answer is B

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

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Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may not be responsive to the unique cultural needs of each client.
B. Focusing solely on hospital unit workflow prioritizes efficiency over individualized patient care, which may not respect cultural differences.
C. This approach fails to acknowledge the diverse values and beliefs of clients, which can lead to miscommunication and unmet needs.
D. This implies a top-down approach to care, which may disregard the client’s preferences and cultural context.
E. Honoring the client's differences and perspectives demonstrates the nurse's commitment to culturally responsive care, ensuring that care is tailored to meet the unique needs of each client.

A. Cutaneous pain B. Parasympathetic pain C. Visceral pain D. Deep somatic pain E. Neuropathic pain

Correct Answer is E

Explanation

A. Cutaneous pain refers to pain from the skin and subcutaneous tissues, which is not described here.
B. Parasympathetic pain is not a recognized category of pain.
C. Visceral pain arises from internal organs and does not typically present as sharp, tingling, or numb.
D. Deep somatic pain is related to muscles, joints, and bones and typically does not have the sharp, tingling quality described.
E. Neuropathic pain is characterized by sharp, tingling sensations and numbness, often resulting from nerve damage, which fits the client's description.

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The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is E

Explanation

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Correct Answer is E

Explanation

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