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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.

This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.

B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.

This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.

C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.

This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.

D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.

A. Maxillary sinusitis B. Nasal polyps. C. Frontal sinusitis. D. Posterior epistaxis.

Correct Answer is A

Explanation

A. Maxillary sinusitis:

Explanation: The client's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and dull, throbbing pain in the cheeks and teeth on the right side, especially when palpated, are indicative of maxillary sinusitis. Maxillary sinusitis refers to the inflammation of the maxillary sinuses, which are located in the cheek area. The symptoms described align with a bacterial infection in this sinus.

B. Nasal polyps:

Explanation: Nasal polyps are soft, noncancerous growths on the lining of the nasal passages or sinuses. While they can cause nasal congestion and a runny nose, they do not typically present with the specific symptoms mentioned in the scenario, such as facial pain, fever, and purulent discharge.

C. Frontal sinusitis:

Explanation: Frontal sinusitis involves inflammation of the frontal sinuses located in the forehead area. Symptoms may include forehead pain, headache, and nasal discharge. However, the described symptoms in the scenario (dull, throbbing pain in the cheeks and teeth on the right side) are more characteristic of maxillary sinusitis.

D. Posterior epistaxis:

Explanation: Posterior epistaxis refers to a nosebleed that originates from the back of the nose, often due to bleeding from the sphenopalatine artery. While nosebleeds can cause blood drainage into the throat and result in a metallic taste, the other symptoms described in the scenario, such as facial pain, fever, and purulent discharge, are not indicative of posterior epistaxis.

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The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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