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 D

Explanation

A. Vagus: The vagus nerve (cranial nerve X) is involved in regulating autonomic functions, such as heart rate and digestion. It does not play a significant role in controlling jaw movements or clenching.
B. Facial: The facial nerve (cranial nerve VII) controls facial expressions, such as smiling or frowning, and also contributes to taste sensation in the anterior two-thirds of the tongue. While it is related to facial motor function, it does not control the jaw muscles responsible for clenching.
C. Glossopharyngeal: The glossopharyngeal nerve (cranial nerve IX) is involved in taste sensation on the posterior one-third of the tongue, as well as in swallowing and salivation. It does not control the jaw muscles used for clenching.
D. Trigeminal: The trigeminal nerve (cranial nerve V) is responsible for sensation in the face and motor functions related to chewing. It innervates the muscles of mastication, including those involved in clenching the jaw. The client’s jaw clenching is a direct manifestation of motor function associated with the trigeminal nerve.

A. Tricuspid and mitral B. Mitral and aortic C. Aortic and pulmonic D. Pulmonic and tricuspid

Correct Answer is C

Explanation

A) Tricuspid and mitral: The tricuspid and mitral valves are best auscultated over the areas where the heart's valves are closest to the chest wall, specifically at the lower left sternal border and the apex, respectively. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of these valves.
B) Mitral and aortic: The mitral valve is auscultated at the apex, and the aortic valve is best heard at the 2nd intercostal space right sternal border. While a louder S2 may be associated with the aortic valve, it is not consistent with the mitral valve.
C) Aortic and pulmonic: The aortic valve and pulmonic valve are located in the areas where S2 (second heart sound) is predominantly heard. The aortic valve is located at the 2nd intercostal space right sternal border, and the pulmonic valve is heard at the 2nd intercostal space left sternal border. A louder S2 in the 2nd intercostal space right sternal border indicates a louder closure of the aortic valve and potentially the pulmonic valve as well.
D) Pulmonic and tricuspid: The pulmonic valve is auscultated at the 2nd intercostal space left sternal border, while the tricuspid valve is heard best at the lower left sternal border. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of the tricuspid valve.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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