During an assessment for jugular vein distension of a client with right sided heart failure (HF), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?

Document the findings as observed.

Repeat without using the lighting.

Flex the client's neck with a pillow and repeat assessment.

Position the client supine and repeat the assessment.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Document the findings as observed: Jugular vein distention (JVD) observed bilaterally in a client with right-sided heart failure while in a semi-Fowler’s position and using proper lighting is an abnormal but expected finding. Since the technique was performed correctly, the nurse should document the findings accurately in the client's medical record for appropriate clinical follow-up.

B. Repeat without using the lighting: Tangential lighting is specifically used to better visualize venous distention and pulsations. Eliminating the lighting would make it harder to see the veins and does not improve the accuracy of the assessment, making repetition without lighting unnecessary.

C. Flex the client's neck with a pillow and repeat assessment: Flexing the neck may obscure venous return and hinder visualization of the jugular veins. The head should remain in a neutral position with slight elevation for optimal assessment, not flexed.

D. Position the client supine and repeat the assessment: Having the client completely supine can cause the veins to become overly distended even in healthy individuals, which would distort the findings. Semi-Fowler’s position is the correct posture for assessing JVD accurately.

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Correct Answer is B

Explanation

Rationale:
A. Leading questions: Leading questions suggest an answer and can bias the client's response. They may prevent the nurse from obtaining an accurate and full description of the sputum’s characteristics, which is critical for assessing pneumonia severity.

B. Open ended questioning: Open-ended questions encourage the client to describe their symptoms in their own words, providing more detailed and accurate information about sputum color, consistency, and quantity. This technique allows for a fuller understanding of the client’s condition.

C. Closed ended questions: Closed-ended questions limit the client's response to a simple "yes" or "no" or brief answer. While useful later for clarifying details, they do not encourage the rich description needed for initial assessment of sputum characteristics.

D. Detailed questions about a symptom: Detailed questioning is appropriate after an initial broad assessment. First, the nurse should use open-ended questions to gather a general description, then proceed with more detailed or specific inquiries based on the client’s initial response.

A. Review past history for any episodes of a cerebral cortex lesion. B. Continue the assessment of the next pairs of cranial nerves. C. Assess the spinal reflexes for demyelination symptoms. D. Implement neurological (neuro) vital signs every 2 hours to detect Cushing's triad.

Correct Answer is B

Explanation

Rationale:
A. Review past history for any episodes of a cerebral cortex lesion: While a history of cerebral cortex lesions may explain some neurologic deficits, the findings described are consistent with normal age-related changes. Immediately jumping to investigate for cortical damage is unnecessary without stronger evidence of acute or severe dysfunction.

B. Continue the assessment of the next pairs of cranial nerves: Mild reductions in upward gaze, corneal reflex, gag reflex, and high-frequency hearing are common and expected in older adults due to aging of the neurological and sensory systems. The nurse should proceed systematically with the full cranial nerve examination to complete the assessment.

C. Assess the spinal reflexes for demyelination symptoms: Demyelination disorders like multiple sclerosis are rare in older adults without specific symptoms suggesting motor or sensory loss beyond what has been described. The findings here do not immediately suggest demyelination, so spinal reflex testing is not the next priority.

D. Implement neurological (neuro) vital signs every 2 hours to detect Cushing's triad: Cushing's triad indicates serious increased intracranial pressure and includes hypertension, bradycardia, and irregular respirations. The client's described findings do not suggest acute neurological deterioration requiring intensive neurovital monitoring.

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During an assessment for jugular vein distension of a client with right sided heart failure (HF), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is B

Explanation

The nurse is performing a cranial nerve exam on an older adult client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. Which action should the nurse take next?

Correct Answer is B

Explanation

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