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 D

Explanation

Rationale:
A. Inequality in muscle contraction: Inequality in muscle contraction suggests a motor or musculoskeletal problem, not a sensory deficit. Monofilament testing specifically assesses for sensory neuropathy rather than muscle strength or contraction differences.

B. An intention tremor: An intention tremor occurs with voluntary movement and typically indicates cerebellar dysfunction. It is unrelated to monofilament testing, which evaluates sensation, not coordination or movement quality.

C. Slowed capillary refill: Capillary refill assesses peripheral perfusion and vascular status, not sensation. While important for overall circulation evaluation, it is not related to the purpose of monofilament testing.

D. Loss of peripheral sensation: Monofilament testing is used to detect peripheral neuropathy, a common complication of diabetes mellitus. An abnormal finding would be the inability to feel the pressure of the monofilament, indicating a loss of protective peripheral sensation and increased risk for foot injuries and ulcers.

A. Rapid strep test. B. Nitazine pH strip. C. Finger stick glucose. D. Urine dipstick test.

Correct Answer is D

Explanation

Rationale:
A. Rapid strep test: A rapid strep test screens for streptococcal throat infections and is unrelated to urinary symptoms. It would not help identify the cause of painful urination in a client with diabetes mellitus.

B. Nitazine pH strip: Nitazine pH testing is primarily used to assess amniotic fluid leakage in pregnant women, not for urinary tract infections (UTIs). It would not provide helpful information for evaluating dysuria in this situation.

C. Finger stick glucose: While important for monitoring diabetes management, finger stick glucose does not directly address the acute complaint of painful urination. It would not diagnose a urinary tract infection, which is the immediate concern.

D. Urine dipstick test: A urine dipstick test screens for leukocytes, nitrites, blood, and glucose in the urine and is the appropriate first screening for suspected UTI. Clients with uncontrolled diabetes are at higher risk for UTIs, and the dipstick can quickly detect infection-related changes.

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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

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

Correct Answer is D

Explanation

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

Correct Answer is D

Explanation

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