A nurse is analyzing assessment findings for several clients. Which finding would be expected?
An older adult client who has a right carotid artery bruit.
An adult client with a heave that is palpable on the anterior chest.
An adult client with a difference of 6 beats between the radial and apical pulse.
An older adult client whose blood pressure has gradually increased with age.
The Correct Answer is D
Choice A reason: A carotid artery bruit is an abnormal, blowing sound heard on auscultation that indicates turbulent blood flow, usually due to atherosclerotic narrowing. This is a pathological finding indicative of potential cerebrovascular disease and is never considered an expected or "normal" finding regardless of the client's age.
Choice B reason: A heave, or lift, is a visible or palpable pulsation of the chest wall that occurs with ventricular hypertrophy. This indicates the heart is working against high pressure or volume, which is a sign of underlying cardiac pathology rather than a healthy, expected physical assessment finding.
Choice C reason: A difference between the apical and radial pulse, known as a pulse deficit, indicates that some cardiac contractions are not strong enough to perfuse to the peripheral extremities. This is frequently seen in conditions like atrial fibrillation and is considered an abnormal hemodynamic finding.
Choice D reason: As humans age, the systemic arteries often lose elasticity and become more rigid, a process known as arteriosclerosis. This increase in vascular resistance leads to a gradual, physiological rise in systolic blood pressure, making it an expected finding in the geriatric population compared to younger adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The second intercostal space is the appropriate location for auscultating the aortic and pulmonic valves at the base of the heart, not the apex. Using the bell in this area is typically reserved for detecting low-pitched murmurs rather than the high-pitched S1 and S2 heart sounds.
Choice B reason: The apex of the heart, where the mitral valve is best heard, is located at the fifth intercostal space at the left midclavicular line. The diaphragm is the correct tool for this assessment because it is designed to pick up high-pitched sounds like S1 and S2.
Choice C reason: The fourth intercostal space along the left sternal border is the traditional site for auscultating the tricuspid valve. While closer to the apex than the second intercostal space, it does not provide the clearest acoustics for the apical impulse or mitral valve closure.
Choice D reason: The third intercostal space at the left sternal border, known as Erb's point, is a common site to hear both aortic and pulmonic murmurs. However, it is not the anatomical location of the apex, and the diaphragm is better utilized at the fifth intercostal space.
Correct Answer is A
Explanation
Choice A reason: Hypotension (82/53 mmHg) combined with new-onset confusion indicates inadequate cerebral perfusion and potential cardiogenic shock. This is a critical medical emergency requiring immediate fluid resuscitation or vasopressor support to prevent multi-organ failure. Confusion is a primary sign of end-organ hypoperfusion that demands the highest priority.
Choice B reason: A heart murmur and a heart rate of 89 beats per minute are relatively stable findings. Many cardiac patients have chronic valvular issues that produce murmurs. A heart rate under 100 is within normal limits, suggesting this client is currently hemodynamically compensated and does not require emergency intervention.
Choice C reason: Stable angina is characterized by predictable chest pain that occurs with exertion and is specifically relieved by rest or nitroglycerin. Since the client reports the pain is relieved, they are not currently experiencing acute myocardial ischemia, making them a lower priority than someone with active hypotension.
Choice D reason: Worsening edema in a heart failure patient indicates fluid volume overload and a gradual decline in cardiac compensation. While this requires a change in diuresis or medication, it is typically a chronic progression rather than an acute, life-threatening event like the hypoperfusion seen in shock.
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