When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Clavicle.

Lung apex.

Aortic site.

Sternum.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.

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Correct Answer is A

Explanation

Choice A rationale
Intranasal edema and swelling of turbinates are classic signs of allergic rhinitis. Allergic rhinitis is an inflammatory response to allergens, leading to swelling and congestion in the nasal passages. The turbinates, which are structures inside the nose that help filter and humidify the air, become swollen due to the inflammatory response, causing symptoms such as nasal congestion, runny nose, and sneezing.
Choice B rationale
Purulent secretions from the eyes and nares are more indicative of an infection, such as bacterial sinusitis or conjunctivitis, rather than allergic rhinitis. Allergic rhinitis typically involves clear, watery secretions rather than purulent (pus-like) discharge.
Choice C rationale
Snoring and bilateral, pale gray nodules are suggestive of nasal polyps, which can occur in chronic rhinosinusitis but are not specific to allergic rhinitis. Nasal polyps are non-cancerous growths that can obstruct nasal passages and cause breathing difficulties.
Choice D rationale
Eye tearing and thick yellow nasal drainage are more characteristic of an infection, such as bacterial sinusitis or conjunctivitis. Allergic rhinitis usually causes clear, watery secretions and may involve eye symptoms like itching and tearing, but not thick yellow drainage.

A. Observe pupil size when focusing on a near object and then a far object. B. Determine if dilation of the pupils occurs when the room is darkened. C. Note the speed of pupil constriction when a penlight is shined into the eye. D. Compare the shape of each of the pupils bilaterally with normal room light.

Correct Answer is A

Explanation

Choice A rationale
Observing pupil size when focusing on a near object and then a far object assesses the accommodation reflex. This reflex involves the pupils constricting when focusing on a near object and dilating when focusing on a far object. This response is mediated by the parasympathetic nervous system and is a normal physiological reaction to changes in focal distance.
Choice B rationale
Determining if dilation of the pupils occurs when the room is darkened assesses the pupillary light reflex, not accommodation. The pupillary light reflex involves the pupils dilating in low light conditions to allow more light to enter the eye, which is controlled by the sympathetic nervous system.
Choice C rationale
Noting the speed of pupil constriction when a penlight is shined into the eye assesses the direct and consensual light reflexes. This test evaluates the function of the optic and oculomotor nerves and is not related to the accommodation reflex.
Choice D rationale
Comparing the shape of each of the pupils bilaterally with normal room light assesses for anisocoria or differences in pupil size, which can indicate neurological issues. This assessment does not evaluate the accommodation reflex.

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When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being evaluated for environmental allergies. While examining the client’s nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Correct Answer is A

Explanation

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

Correct Answer is A

Explanation

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