During an assessment, where would the nurse best auscultate for a tricuspid valve murmur?

second right intercostal space at the sternal border

fourth left intercostal space at the sternal border

Fifth left intercostal space at the midclavicular line

second left intercostal space at the sternal border

Answer and Explanation

The Correct Answer is B

A. Second right intercostal space at the sternal border: This location is primarily used to auscultate the aortic valve. The second intercostal space on the right side corresponds to the aortic area, where sounds related to aortic valve closure and potential murmurs can be best heard. Therefore, this location is not appropriate for assessing tricuspid valve murmurs.
B. Fourth left intercostal space at the sternal border: This is the correct location to auscultate the tricuspid valve. The tricuspid valve is situated between the right atrium and right ventricle, and the best location to hear any associated murmurs is at the left lower sternal border, specifically around the fourth intercostal space. Murmurs due to tricuspid regurgitation or stenosis would be detected most clearly here.
C. Fifth left intercostal space at the midclavicular line: This location is primarily associated with the mitral valve, which is situated at the apex of the heart. While some left-sided heart murmurs may be faintly heard in this area, it is not the optimal location for assessing the tricuspid valve. Therefore, it does not serve as the best choice for detecting tricuspid murmurs.
D. Second left intercostal space at the sternal border: This location is typically used to auscultate the pulmonic valve, which is situated at the left side of the heart, above the left ventricle. Although the pulmonic area is important in heart assessments, it is not relevant for identifying tricuspid valve murmurs, making this choice unsuitable.

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Correct Answer is B

Explanation

A. Once the speculum is in the ear, releasing the traction: Releasing traction too soon can lead to collapse of the ear canal, obstructing the view of the tympanic membrane. Maintaining traction throughout the examination ensures a clear view and prevents discomfort.

B. Pulling the pinna up and back before inserting the speculum: The correct technique for an adult involves pulling the pinna up and back to straighten the external auditory canal, allowing for an unobstructed view of the tympanic membrane. In children under three, the pinna is pulled down and back due to the more horizontal orientation of the ear canal.

C. Tilt the person's head forward during the examination: The head should remain upright or slightly tilted away from the examiner to provide better access to the ear canal. Tilting forward is unnecessary and may not improve visualization.

D. Using the smallest speculum to decrease the amount of discomfort: A speculum that is too small may not provide a sufficient view of the tympanic membrane. The largest speculum that comfortably fits should be used to allow for optimal visualization.

A. XI; have patient shrug their shoulders against resistance. B. XI; palpate the anterior and posterior triangles. C. XII; assess for a positive Romberg sign. D. XII; percuss the sternomastoid and submandibular neck muscles.

Correct Answer is A

Explanation

A. XI; have patient shrug their shoulders against resistance: Cranial nerve XI, also known as the accessory nerve, is responsible for the innervation of the sternocleidomastoid and trapezius muscles. Damage to this nerve can lead to weakness in shoulder shrugging and difficulty turning the head. Asking the patient to shrug their shoulders against resistance allows the nurse to assess the function of this nerve effectively.

B. XI; palpate the anterior and posterior triangles: While palpating the anterior and posterior triangles of the neck can provide useful anatomical information, it does not specifically assess the function of cranial nerve XI. This action may not directly address the patient's complaints or evaluate nerve function adequately.

C. XII; assess for a positive Romberg sign: Cranial nerve XII, the hypoglossal nerve, is responsible for tongue movement. The Romberg test assesses balance and proprioception, not directly related to neck and shoulder pain or head movement. This option is not appropriate in this context.

D. XII; percuss the sternomastoid and submandibular neck muscles: Percussion is not a standard method for assessing cranial nerve function and would not provide useful information about nerve damage. This option also incorrectly identifies the relevant cranial nerve, as cranial nerve XII is not involved in neck and shoulder movement.

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During an assessment, where would the nurse best auscultate for a tricuspid valve murmur?

Nursing Test Bank

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Correct Answer is A

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