A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

to check radial pulses

to assess pedal pulses

to assess jugular filling pressure

to auscultate lung sounds

Answer and Explanation

The Correct Answer is C

A) To check radial pulses: Radial pulses are typically assessed by palpation at the wrist. A gooseneck lamp is not necessary for this task; standard lighting and direct palpation are usually sufficient.
B) To assess pedal pulses: Pedal pulses are assessed by palpation on the top of the foot. A gooseneck lamp is not needed for this purpose, as the lighting conditions are generally adequate for palpation in a well-lit room.
C) To assess jugular filling pressure: Assessing jugular venous pressure (JVP) requires good lighting to clearly see the pulsations in the jugular veins. A gooseneck lamp provides focused and adjustable lighting, which is helpful for this assessment. This ensures accurate observation of the jugular veins and helps in evaluating the severity of heart failure.
D) To auscultate lung sounds: Auscultating lung sounds involves using a stethoscope and does not typically require a gooseneck lamp. Proper lighting is not essential for auscultation, as the focus is on auditory assessment rather than visual inspection.

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Correct Answer is A

Explanation

A) Range of motion: Lateral bending of the spine is a movement used to assess the range of motion (ROM) of the spine, specifically the flexibility and mobility of the thoracolumbar region. By asking the client to perform lateral bends, the nurse can evaluate the extent to which the client can bend sideways and assess any limitations or discomfort in the movement.
B) Diaphragmatic excursion: Diaphragmatic excursion refers to the movement of the diaphragm during respiration and is assessed through techniques like percussion and auscultation of the lungs. Lateral bending of the spine does not provide information about diaphragmatic movement.
C) Spinous processes: The spinous processes of the vertebrae can be palpated to assess alignment and tenderness, but lateral bending does not specifically assess the spinous processes. It focuses more on the overall mobility of the spine.
D) Spinal deformities: While lateral bending can reveal limitations in spinal movement that might suggest underlying spinal deformities, it is not a primary diagnostic tool for identifying specific deformities. Other assessments, such as inspection and palpation of the spine, X-rays, or physical

A. angioedema B. actinic cheilitis C. angular cheilitis D. herpes simplex

Correct Answer is D

Explanation

A. Angioedema: Angioedema is characterized by deep swelling of the skin and mucous membranes, often caused by allergic reactions. It usually affects areas like the lips, eyes, or throat but does not typically present with vesicular eruptions.
B. Actinic cheilitis: Actinic cheilitis results from chronic sun exposure leading to changes in the lips' texture and color. It typically presents as dry, scaly patches or discoloration, not vesicular eruptions.
C. Angular cheilitis: Angular cheilitis involves inflammation and cracking at the corners of the mouth, often due to fungal or bacterial infection. It does not typically present with vesicular eruptions.

D. Herpes simplex: Herpes simplex virus commonly causes vesicular eruptions on the lips and surrounding skin, known as cold sores or fever blisters. These eruptions are characteristic of the herpes simplex infection and align with the description of vesicular eruptions observed in the client.

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A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about?

Correct Answer is A

Explanation

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?

Correct Answer is D

Explanation

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A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

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