A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

Place the diaphragm against the client's clothing and angle biannuals toward nose.

Ensure that the ear pieces are loose and comfortable in ears.

Ask the client to hold their breath during auscultation.

Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces.

Answer and Explanation

The Correct Answer is D

A. Placing the diaphragm against clothing can interfere with sound transmission. The stethoscope should be placed directly on the skin.
B. Earpieces should fit snugly in the ears to optimize sound conduction, rather than being loose.
C. Asking the client to hold their breath is not a standard technique for improving heart sound auscultation; it is more useful for breath sounds or murmurs.
D. "Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces" is correct because background noise can interfere with auscultation, and a proper fit enhances sound transmission.

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Correct Answer is C

Explanation

A. Clubbing of the fingers is a chronic finding associated with long-term hypoxia from respiratory diseases such as chronic lung disease or cystic fibrosis, not acute heart failure.
B. Bilateral crepitus suggests air trapping or alveolar collapse, which is more indicative of pneumonia or emphysema, rather than a primary cardiac cause.
C. Bilateral peripheral edema is correct. Dyspnea that worsens when lying flat (orthopnea) and the need for multiple pillows to sleep comfortably are signs of heart failure. Peripheral edema indicates fluid overload due to poor cardiac function.
D. Increased anteroposterior diameter is associated with chronic respiratory conditions like COPD, where lung hyperinflation leads to a "barrel chest" appearance. This is not a typical finding in heart failure.

A. Thinning of the vertebral discs leads to weight loss. B. An increase in lean body mass leads to weight gain. C. Spinal kyphosis contributes to the increase in body weight. D. Loss of muscle tissue contributes to the decrease in weight.

Correct Answer is D

Explanation

A. Thinning of the vertebral discs leads to a decrease in height, not weight.
B. Lean body mass actually decreases with aging, contributing to weight loss rather than gain.
C. Spinal kyphosis affects posture but does not significantly contribute to changes in body weight.
D. Loss of muscle tissue (sarcopenia) is correct because aging leads to a decline in muscle mass, which contributes to weight loss. Additionally, a slower metabolism and reduced physical activity further affect body composition.

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A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

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Naxlex Comprehensive Predictor Exams

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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