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 C

Explanation

A. Xerostomia: Xerostomia refers to dry mouth, which is caused by reduced saliva production. While it can be a symptom of various conditions, it is not directly associated with facial drooping after a stroke.

B. Epistaxis: Epistaxis is a medical term for a nosebleed. It occurs due to the rupture of small, delicate blood vessels within the nose. While it can happen independently of a stroke, it is not directly related to facial drooping caused by a stroke.

C. Dysphagia: Dysphagia refers to difficulty in swallowing, which can occur after a stroke due to muscle weakness, including the facial muscles. Facial drooping on one side can be indicative of stroke-related muscle weakness and can contribute to difficulties in swallowing.

D. Rhinorrhea: Rhinorrhea is the medical term for a runny nose, where the nasal cavity is filled with a significant amount of mucus. It is usually caused by various factors such as allergies, infections, or irritants. Rhinorrhea is not directly associated with facial drooping after a stroke.

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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Explanation

Correct Answer is A

Explanation

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