When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?

Left fifth intercostal space, midclavicular line.

Third left intercostal space.

Left fourth intercostal space next to left sternal border.

Second right intercostal space.

Answer and Explanation

The Correct Answer is C

A.   The fifth intercostal space, midclavicular line, is the location for auscultating the mitral valve.
B.   The third left intercostal space is typically used for the pulmonic valve.
C.   The tricuspid valve is best auscultated at the left fourth intercostal space near the left sternal border.
D.   The second right intercostal space is used to listen to the aortic valve.

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Correct Answer is D

Explanation

A. Observing pupillary response to a penlight helps assess the neurological function related to the eyes, such as reaction to light, but it does not directly assess the client's overall visual acuity or support the claim of being legally blind.
B. Examining the optic disc can help identify structural changes in the eye, such as damage to the retina or optic nerve, but it doesn't directly assess the client’s claim of being legally blind or the extent of visual impairment.
C. Assessing eye movements can help evaluate for conditions such as strabismus or cranial nerve abnormalities, but it doesn't provide a direct assessment of visual acuity or support the client’s statement of blindness.
D. The Snellen chart is a standard tool for assessing visual acuity and is the most appropriate method to objectively measure whether the client has the visual impairment consistent with being legally blind.

A. Blowing, hollow sounds above sternum. B. Slight crackling throughout lung fields. C. Faint whistling over both lung bases. D. Right breath sounds louder than left.

Correct Answer is D

Explanation

A. Blowing or hollow sounds above the sternum are abnormal and may suggest a condition like aortic or pulmonary disease. Such sounds are not typical during routine chest auscultation and may indicate pathology like bronchial obstruction or an abnormal vascular sound.
B. Slight crackling sounds, also known as "rales" or "crackles," may be indicative of fluid accumulation in the lungs, often seen in conditions like pneumonia or congestive heart failure. These are not considered normal findings and warrant further evaluation.
C. Faint whistling sounds may be indicative of wheezing, which is often a sign of airway narrowing or obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD). Wheezing is not typically considered normal and should be investigated further.
D. Right-sided breath sounds being louder than the left could be a normal finding in certain individuals, depending on factors like body position or anatomical variations. In a healthy individual, this difference may not indicate pathology unless associated with other symptoms such as asymmetry in lung sounds or dyspnea.

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When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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