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 A

Explanation

A) Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation, typically occurring at the end of inspiration. These crackles are often heard in the bases of the lungs, particularly when the client is in a supine position, and are not associated with any pathological condition. Atelectatic crackles are a normal finding, especially in a sleeping or newly awakened client, as they result from the temporary collapse of small airways that quickly re-expand. Since they disappear after a few breaths and are not indicative of disease, they should be documented as atelectatic crackles without a pathological cause.

B) Fine crackles that may be a sign of impending pneumonia:
Fine crackles are high-pitched, popping sounds that are often heard during inspiration, especially at the lung bases. They are commonly associated with conditions like pneumonia, heart failure, or pulmonary fibrosis. However, in this case, the crackles heard stopped after a few breaths, which is characteristic of atelectatic crackles rather than fine crackles associated with pathological conditions. Fine crackles that last and occur consistently may suggest pathology, but in this scenario, the transient nature of the sounds points to atelectatic crackles, not pneumonia.

C) Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung fields, characterized by a soft, low-pitched sound during inspiration, with a shorter expiration. These sounds are different from crackles, which are brief, popping sounds. Vesicular breath sounds do not refer to abnormal or adventitious sounds, such as the crackles heard in this client. Therefore, the nurse should not document the breath sounds as vesicular.

D) Fine wheezes:
Wheezes are continuous musical sounds produced by the narrowing of the airways, typically heard during exhalation. They are usually caused by conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. The crackling sounds described in the question are not wheezes, as they are short, popping sounds rather than musical, continuous sounds. The transient nature of the sounds makes them more consistent with atelectatic crackles, not wheezes.

A. Dysphagia B. Rhinitis C. Xerostomia D. Epistaxis

Correct Answer is A

Explanation

A. Dysphagia:
Dysphagia, or difficulty swallowing, is a common issue in clients who have had a stroke, particularly when there is facial drooping or weakness on one side of the face, which can affect the muscles involved in swallowing. A stroke can cause motor impairment, affecting the coordination and strength required for effective swallowing. This condition increases the risk of aspiration (food or liquid entering the airway), which can lead to respiratory complications such as pneumonia. It is crucial to assess for dysphagia in stroke patients and provide appropriate interventions, such as speech therapy and modified diets, to ensure safe swallowing.

B. Rhinitis:
Rhinitis, which refers to inflammation of the nasal passages causing symptoms like congestion, sneezing, and runny nose, is not directly related to stroke. Although rhinitis can be caused by allergies, infections, or environmental irritants, it is not a typical finding following a stroke. The presence of facial drooping on one side is more suggestive of a neurological issue affecting motor control, rather than an issue with the nasal passages or upper respiratory system.

C. Xerostomia:
Xerostomia, or dry mouth, can occur for various reasons, such as medication side effects or dehydration, but it is not a primary concern directly associated with stroke-induced facial drooping. While facial nerve dysfunction can affect salivation (since the facial nerve helps control the salivary glands), dysphagia and facial drooping are more immediate concerns for stroke patients. Xerostomia may occur in some cases, but it is not as directly linked to stroke as dysphagia is.

D. Epistaxis:
Epistaxis, or nosebleeds, is not a typical complication of stroke and is not associated with facial drooping. While certain factors like dry air, medications (e.g., anticoagulants), or trauma could cause nosebleeds, they are not common findings directly related to a stroke. The focus should be on potential neurological deficits, such as difficulty swallowing, impaired speech, or weakness, rather than epistaxis.

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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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