A nurse is completing an assessment o a client suspected of having a carotid artery blockage. Which of the following techniques should the nurse to assess the client's carotid arteries?

Simultaneously palpating both arteries to compare amplitude

Auscultating the artery at the base of the neck at the carotid bifurcation

Listening with the diaphragm of the stethoscope to assess for bruits

Instructing the client to take deep breaths during auscultation

Answer and Explanation

The Correct Answer is B

A) Simultaneously palpating both arteries to compare amplitude: Palpating both carotid arteries simultaneously is contraindicated as it can obstruct blood flow to the brain, potentially causing a decrease in cerebral perfusion and leading to syncope or other complications. Each artery should be palpated one at a time to prevent this risk.

B) Auscultating the artery at the base of the neck at the carotid bifurcation: The correct technique for assessing for carotid artery blockage is to auscultate the artery at the carotid bifurcation, which is located at the base of the neck. The nurse should use the bell of the stethoscope to listen for bruits, which are abnormal sounds caused by turbulent blood flow due to narrowing or blockage of the artery. This is a non-invasive method used to detect vascular abnormalities.

C) Listening with the diaphragm of the stethoscope to assess for bruits: The diaphragm of the stethoscope is generally used for high-pitched sounds like lung and bowel sounds. For auscultating bruits, the bell of the stethoscope is preferred because it is more sensitive to low-pitched sounds, which are characteristic of bruits caused by turbulent blood flow in narrowed arteries.

D) Instructing the client to take deep breaths during auscultation: Instructing the client to take deep breaths is unnecessary and could alter the sound being auscultated. The nurse should have the client breathe normally to avoid interference with the auscultation of the carotid arteries. The goal is to listen for any abnormal sounds (bruits) without any external factors affecting the findings.

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Correct Answer is D

Explanation

A) Crackles: Crackles are abnormal lung sounds often associated with conditions such as pneumonia, heart failure, or pulmonary edema. They result from fluid in the airways or alveoli. However, crackles are not typically the primary finding in pleuritis, which involves inflammation of the pleura.

B) Stridor: Stridor is a high-pitched wheezing sound caused by an obstruction or narrowing of the upper airway, often seen in conditions such as croup or anaphylaxis. It is not characteristic of pleuritis, which involves inflammation of the pleura and not airway obstruction.

C) Dyspnea: Dyspnea, or difficulty breathing, is a common symptom in many respiratory conditions, including pleuritis. While pleuritis can lead to discomfort during breathing, dyspnea itself is not a sound that would be auscultated. It’s a subjective feeling that would be noted during the client’s history or verbal report, rather than an auscultatory finding.

D) Friction rub: A pleural friction rub is the most expected finding when auscultating a client with pleuritis. This sound occurs when the inflamed pleural layers rub against each other during breathing, producing a grating, scratchy sound. The nurse will typically hear this sound best on inspiration or expiration and it is the hallmark sign of pleuritis. The presence of a friction rub indicates the pleural inflammation characteristic of this condition.

A. II B. I C. VI D. IV

Correct Answer is A

Explanation

A) II:
This is the correct answer. The optic nerve (cranial nerve II) is responsible for visual acuity, as it transmits visual information from the retina to the brain. When assessing visual acuity, the nurse is evaluating the function of the optic nerve, which is responsible for the sense of vision. Therefore, cranial nerve II should be assessed during a visual acuity exam.

B) I:
This is incorrect. The olfactory nerve (cranial nerve I) is responsible for the sense of smell, not vision. Visual acuity is not related to the olfactory nerve, so it is not involved in this type of assessment.

C) VI:
This is incorrect. The abducens nerve (cranial nerve VI) controls the lateral rectus muscle of the eye, which is responsible for outward eye movement. While cranial nerve VI plays a role in eye movement, it is not directly involved in measuring visual acuity, which pertains to the function of the optic nerve.

D) IV:
This is incorrect. The trochlear nerve (cranial nerve IV) controls the superior oblique muscle, which helps with eye movement, specifically downward and inward eye movements. This nerve is not involved in measuring visual acuity.

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A nurse is completing an assessment o a client suspected of having a carotid artery blockage. Which of the following techniques should the nurse to assess the client's carotid arteries?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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