The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?
Listening for all possible sounds at a time at each specified area.
Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.
Listening to the sounds only at the site where the apical pulse is felt to be the strongest.
Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.
The Correct Answer is D
A. Listening for all possible sounds at a time at each specified area: This approach does not allow for specific localization of different heart sounds and murmurs, making it difficult to accurately assess the heart's condition.
B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This option is close but lacks the systematic approach of method D. Listening at specific anatomical locations (aortic, tricuspid, pulmonic, mitral) is important, but the Z pattern allows for thorough coverage and precise localization of any abnormal sounds.
C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest: This method does not cover all the important auscultation sites on the heart and may miss significant findings.
D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex: This technique involves a systematic approach where the nurse listens at specific locations in a structured manner, ensuring comprehensive coverage of the heart sounds and murmurs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The eyes converge to focus on the light.
This statement refers to the convergence reflex, where both eyes move medially (towards each other) to maintain single binocular vision when focusing on a near object. It is not related to the pupillary light reflex, which involves changes in pupil size in response to light.
B. The eye focuses the image in the center of the pupil.
This choice does not accurately describe the pupillary light reflex. The pupillary light reflex involves constriction of the pupil in response to light, not focusing an image in the center of the pupil.
C. Dilation of both pupils occurs in response to bright light.
This statement is incorrect. In response to bright light, the pupils should constrict, not dilate. Dilation of pupils in bright light could indicate an abnormal response, such as in cases of certain neurological conditions or drug use.
D. Constriction of both pupils occurs in response to bright light.
This choice is correct. In the pupillary light reflex, both pupils constrict when exposed to bright light. This response is a protective mechanism to prevent excessive light from entering the eyes, ensuring optimal visual acuity.
Correct Answer is B
Explanation
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 shouldnotpalpate the carotid artery. A bruit suggests partial obstruction (carotid stenosis), and compressing the artery further could worsen blood flow.
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