The client is a 35-year-old male with no history of any medical conditions is in the clinic for an annual physical.

Exhibits

Nurse analyzes the findings.

What can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Choice A Reason:
Listening while the client reads items listed on the menu is inappropriate. This approach involves assessing the client's speech while they read items listed on the menu. While reading aloud can provide some insight into speech patterns, it may not fully capture spontaneous speech or natural conversation. Additionally, reading may not necessarily assess other aspects of speech such as articulation, fluency, or coherence. Therefore, while this approach can offer some information, it may not be as comprehensive as observing speech during a natural conversation or interview.
Choice B Reason:
Asking the client to complete a common proverb or saying is inappropriate. Asking the client to complete a common proverb or saying is a task that assesses language comprehension and expression. While this approach may provide some insight into the client's ability to formulate and articulate speech, it may not fully capture spontaneous speech patterns or natural conversation. Additionally, completing proverbs or sayings may require specific cultural knowledge or cognitive abilities that could influence the assessment. Therefore, while this approach can be useful in certain contexts, it may not be as comprehensive as observing speech during a natural conversation or interview.
Choice C Reason:
Noting the client's responses during the initial interview is appropriate. Option C involves observing the client's speech patterns during the initial interview, which provides the nurse with an opportunity to assess spontaneous speech, articulation, fluency, and coherence. During the initial interview, the nurse can assess the client's ability to express thoughts, respond to questions, and engage in conversation, which can reveal any abnormalities or difficulties in speech patterns. This approach allows for a comprehensive assessment of speech without requiring specific tasks or prompts that may be more challenging or unfamiliar to the client.
Choice D Reason:
Having the client repeat a phrase containing alliteration is inappropriate. Asking the client to repeat a phrase containing alliteration is a task that assesses speech articulation and phonological skills. While this approach may provide some information about the client's ability to produce specific sounds or syllables, it may not fully capture spontaneous speech patterns or natural conversation. Additionally, repeating phrases with alliteration may not necessarily assess other aspects of speech such as fluency, coherence, or language comprehension. Therefore, while this approach can be useful for assessing specific speech skills, it may not be as comprehensive as observing speech during a natural conversation or interview.

Choice A Reason:
Testing feet for a positive Babinski reflex is wrong. The Babinski reflex is a neurological test that assesses upper motor neuron function, particularly in the lower extremities. However, it is not relevant to assessing cold feet, and testing for the Babinski reflex would not provide useful information in this situation.
Choice B Reason:
Observing color of the feet and toes is wright. Observing the color of the feet and toes can provide important information about circulation. Pallor, cyanosis, or mottling may indicate inadequate blood flow or perfusion to the extremities, which could contribute to cold feet.
Choice C Reason:
Measuring skin elasticity around the ankles is wrong. Skin elasticity assessment is more relevant for evaluating hydration status or tissue turgor. While it may be useful in certain contexts, it is not directly related to assessing cold feet and peripheral circulation. Therefore, it is not necessary before covering the client's feet in this scenario.
Choice D Reason:
Assessing volume of the pedal pulses is wright. Assessing the volume of the pedal pulses (such as dorsalis pedis and posterior tibial pulses) provides information about peripheral vascular status. Weak or absent pulses may indicate compromised circulation, contributing to cold feet.
Choice E Reason:
Palpating dorsal surface of feet for warmth is wright. palpating the dorsal surface of the feet for warmth helps assess peripheral perfusion. Coolness to touch may indicate decreased blood flow to the extremities, while warmth suggests adequate circulation.