Exhibits

Drag from Word Choices to complete the sentence.

Heart sounds are loudest for S1 at the
dropdown
. And for S2 at the
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Rationale:

• Center of the heart: The center of the heart is not an anatomical landmark used to differentiate heart sounds. Heart sounds are best heard at specific points related to valve locations, and the "center" does not correspond to where S1 or S2 are loudest.

• Apex of the heart: The apex of the heart is located at the fifth intercostal space at the midclavicular line. S1, produced by the closure of the mitral and tricuspid valves, is loudest here because these valves are closest to the apex region.

• Right side of the heart: The right side of the heart involves the tricuspid and pulmonary valves, but it is not a location used for distinguishing where heart sounds are loudest. Both left and right-sided valves contribute to S1 and S2, but loudness is associated with specific auscultation sites, not broadly the right side.

• Base of the heart: The base of the heart is located at the level of the second intercostal space near the sternum. S2, produced by the closure of the aortic and pulmonic valves, is loudest at the base because these semilunar valves are positioned superiorly.

• Left side of the heart: The left side of the heart includes the mitral and aortic valves but saying simply "left side" does not accurately describe where S1 or S2 are best heard. The terms apex and base are used instead because they specifically relate to the loudest points for heart sounds.

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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. Obtain vital signs and oxygen saturation. B. Calculate the body mass index (BMI). C. Measure degree of skin elasticity. D. Compare muscle strength bilaterally.

Correct Answer is D

Explanation

Rationale:
A. Obtain vital signs and oxygen saturation: While vital signs and oxygen saturation provide essential information about cardiovascular and respiratory status, they do not directly assess or explain localized muscle atrophy, which points more toward a musculoskeletal or neurologic issue.

B. Calculate the body mass index (BMI): BMI evaluates overall body weight relative to height and can identify underweight, overweight, or obesity. However, it does not provide specific information about asymmetrical muscle wasting or localized muscle function.

C. Measure degree of skin elasticity: Skin elasticity assessment is useful for hydration status but is unrelated to muscular strength or the presence of atrophy. It would not offer meaningful information about the function or cause of the observed muscle changes.

D. Compare muscle strength bilaterally: Comparing muscle strength on both sides allows the nurse to assess for weakness, nerve impairment, or disuse atrophy. This focused and direct examination is essential to determine the extent and functional impact of the observed muscle wasting.

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Exhibits Drag from Word Choices to complete the sentence. Heart sounds are loudest for S1 at the dropdown. And for S2 at the dropdown

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

In completing a physical assessment of a young adult, the clinic nurse observes muscular atrophy of the right thigh and calf. To gather additional data related to this finding, which action should the nurse take?

Correct Answer is D

Explanation

While completing a health assessment for a client with peripheral vascular disease (PVD), which assessment technique is most important for the nurse to implement?

The nurse is performing a health interview for a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

The nurse is assessing a client's skeletal muscle movements and strength. Which action should the nurse instruct the client to perform to evaluate prime-mover muscle groups?

The nurse is assessing the perianal area of a female client who reports she has chronic constipation and has bright red blood on the toilet paper after having a bowel movement. Which finding should the nurse report to the healthcare provider (HCP) that is most consistent with the client's report?

Exhibits

Drag from Word Choices to complete the sentence.

Heart sounds are loudest for S1 at the
dropdown
. And for S2 at the
dropdown