A nurse is caring for a 76-year-old male client in an outpatient clinic.

Complete the diagram by dragging from the choices below to specify which potential condition the client is possibly experiencing, two actions the nurse should take when assessing the carotid arteries, and two parameters the nurse should continually monitor post initial findings.

Answer and Explanation

The Correct Answer is []

Condition: transient ischemic attack
2 actions: compress gently one carotid at a time, perform a full neurological exam
2 parameters: bruit, pulses

Rationale for correct condition
Transient ischemic attack (TIA) is caused by temporary cerebral ischemia, often due to carotid artery stenosis or embolism. The client’s mild disorientation and carotid bruit suggest impaired cerebral blood flow without permanent infarction. TIAs present as transient neurological symptoms resolving within 24 hours, consistent with intermittent confusion. This condition is a warning sign for potential future stroke and requires urgent evaluation. Early identification and intervention can prevent progression to stroke.

Rationale for correct actions
Compressing gently one carotid artery at a time helps assess pulse quality and detect possible vascular occlusion or stenosis while avoiding bilateral compression that can cause cerebral hypoperfusion. Performing a full neurological exam evaluates cognitive function, motor skills, and sensory deficits, identifying areas affected by transient ischemia and guiding further management. Both actions are essential to assess the extent of vascular and neurological involvement accurately.

Rationale for correct parameters
Monitoring the bruit helps track turbulent blood flow through a narrowed carotid artery, indicating worsening stenosis risk. Assessing pulses ensures adequate peripheral circulation and detects any changes from baseline that could signal embolic events. These parameters help evaluate the vascular status and risk of ischemic events continuously.

Rationale for incorrect conditions
Stroke results in permanent neurological deficits, not transient symptoms; the client is alert and only mildly disoriented. Aortic stenosis affects cardiac outflow, not carotid flow, and is unrelated to confusion or carotid bruits. Carotid artery dissection involves vessel wall injury causing acute symptoms like neck pain and ischemia, which the client lacks.

Rationale for incorrect actions
Having the patient lie down is unnecessary and may not improve cerebral perfusion. Administering supplemental oxygen is not indicated without hypoxia. Applying firm bilateral pressure can dangerously reduce cerebral blood flow causing syncope or stroke.

Rationale for incorrect parameters
Distended jugular veins indicate right heart failure, unrelated to carotid disease. Visual acuity changes are more associated with ophthalmic artery issues, not carotid bruits. Chest pain relates to cardiac ischemia, not carotid vascular assessment.

Take home points

transient ischemic attacks are brief episodes of cerebral ischemia without permanent damage
carotid bruits suggest arterial stenosis and increased stroke risk
neurological exams and careful vascular assessment are critical in TIA evaluation
differentiate TIA from stroke, cardiac causes, and carotid dissection for appropriate treatment

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Correct Answer is B

Explanation

Choice A rationale

Faint whistling over both lung bases, also known as wheezing, indicates narrowed airways due to bronchoconstriction, inflammation, or secretions. This is an abnormal adventitious breath sound, often associated with conditions like asthma, bronchitis, or chronic obstructive pulmonary disease, and is not considered a normal finding during chest auscultation.

Choice B rationale

Blowing, hollow sounds heard above the sternum are characteristic of tracheal or bronchial breath sounds. These sounds are normal when auscultated directly over the trachea or main bronchi because of the rapid airflow through these larger airways. They are louder and higher-pitched than vesicular sounds and are considered a normal finding in this specific anatomical location.

Choice C rationale

Breath sounds over the right lung fields are typically similar in intensity to the left, assuming symmetrical lung expansion and clear airways. If the right breath sounds are distinctly louder than the left, it could indicate an abnormality such as consolidation in the right lung, a pleural effusion on the left, or other pathological conditions affecting sound transmission, making it an abnormal finding.

Choice D rationale

Slight crackling throughout lung fields, commonly referred to as crackles or rales, indicates the presence of fluid or secretions in the alveoli or small airways. These are adventitious sounds, often associated with conditions such as pneumonia, heart failure, or pulmonary fibrosis, and are not a normal finding during respiratory auscultation in healthy individuals.

A. Percuss diaphragmatic excursion. B. Auscultate the client's breath sounds. C. Observe the appearance of the thorax. D. Palpate tactile fremitus on the posterior chest.

Correct Answer is C

Explanation

Choice A rationale

Percussing diaphragmatic excursion assesses the movement of the diaphragm during respiration, reflecting lung expansion and function. While relevant to respiratory assessment, it does not directly confirm the anatomical characteristic of a barrel chest, which is a structural alteration of the thoracic cage.

Choice B rationale

Auscultating breath sounds evaluates airflow through the respiratory passages, identifying adventitious sounds like wheezes or crackles. Although individuals with a barrel chest may have altered breath sounds due to lung hyperinflation, auscultation does not directly confirm the physical presence of the barrel chest deformity itself.

Choice C rationale

Observing the appearance of the thorax allows for direct visual assessment of the anteroposterior (AP) diameter in relation to the transverse diameter. A barrel chest is characterized by an increased AP diameter, often approaching a 1: ratio, which is a key visual diagnostic criterion for this chronic respiratory condition.

Choice D rationale

Palpating tactile fremitus assesses the transmission of vibrations through the lung tissue during vocalization. While providing information about lung consolidation or obstruction, it is not a primary method for confirming the characteristic structural deformity of an increased anteroposterior diameter associated with a barrel chest.

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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