The client is a 35-year-old male with no history of any medical conditions is in the clinic for an annual physical.
Nurse analyzes the findings.
What can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.
Reach under a gown to listen and take care that no clothing rubs on the stethoscope
Ensure the room is as quiet as possible
Keep the examination room warm, and warm the stethoscope
Document the roaring and crackles
Wet the chest hair before auscultating
Correct Answer : A,B,C,E
Choice A Reason:
This option can help minimize clothing-related artifacts that may interfere with auscultation. Ensuring that the stethoscope is in direct contact with the skin allows for better transmission of sounds
Choice B Reason:
Ensuring the room is as quiet as possible is appropriate. Background noise can interfere with the clarity of auscultatory sounds. Ensuring a quiet environment helps reduce external interference and improves the nurse's ability to accurately hear and interpret the sounds.
Choice C Reason:
Keeping the examination room warm, and warm the stethoscope is appropriate. Cold temperatures can cause vasoconstriction and muscle tension, leading to increased tension in the skin and subcutaneous tissues, which may affect the quality of auscultatory sounds. Keeping the examination room warm and warming the stethoscope helps minimize this effect, ensuring clearer auscultation.
Choice D Reason:
Document the roaring and crackles is inappropriate. Documenting auscultatory findings such as roaring and crackles is important for clinical assessment and documentation but does not mitigate artifacts during auscultation. It is crucial to focus on optimizing the auscultation environment and technique to ensure accurate interpretation of sounds.
Choice E Reason:
Wetting the chest hair before auscultating is appropriate. Chest hair can create friction and produce artifacts during auscultation, particularly when using a stethoscope. Wetting the chest hair helps reduce friction and minimize artifacts, allowing for clearer auscultatory sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Get the most difficult questions over with first is not the best approach because starting with the most difficult questions may put the client on the defensive or make them feel uncomfortable, hindering open communication. It's important to build rapport and establish trust with the client before addressing sensitive topics.
Choice B Reason:
Asking questions in a vague, non-specific format is not effective because vague and non-specific questions may result in ambiguous or incomplete responses, making it difficult to gather accurate information about the client's alcohol and substance use. Clear and specific questions are necessary to obtain relevant details.
Choice C Reason:
Sharing personal values to put the client at ease is not recommended as it can compromise the nurse's professional boundaries and may influence the client's responses. The focus of the interview should be on the client, and the nurse should maintain a neutral and non-judgmental stance.
Choice D Reason:
Begin with questions that are less sensitive in nature is the best approach because it allows the nurse to establish rapport and build trust with the client before addressing more sensitive topics such as alcohol and substance use. Starting with less threatening questions helps the client feel more comfortable and willing to disclose information, facilitating open communication and rapport-building.
Correct Answer is D
Explanation
Choice A Reason:
Black tarry stools are inappropriate. Black tarry stools may indicate gastrointestinal bleeding, which is not directly related to the client's symptoms of suprapubic tenderness and pressure after urination. While it's important to consider other potential health issues, such as gastrointestinal bleeding, it may not be directly relevant to the client's current urinary symptoms.
Choice B Reason:
A cloudy discharge is inappropriate. A cloudy discharge may suggest an infection or inflammation in the urinary tract, but it is not specifically associated with the symptoms described by the client (suprapubic tenderness and pressure after urination). While urinary tract infections (UTIs) can occur in older adults, they may present with symptoms such as urinary urgency, frequency, dysuria, and hematuria, rather than suprapubic tenderness and pressure after urination.
Choice C Reason:
An overactive bladder is inappropriate. While overactive bladder can cause urinary urgency and frequency, it is less likely to present with suprapubic tenderness and pressure after urination. Overactive bladder is characterized by sudden, involuntary contractions of the bladder muscles, leading to a frequent and urgent need to urinate. It may not directly explain the client's symptoms of suprapubic tenderness and pressure after urination, which are more suggestive of urinary obstruction due to BPH.
Choice D Reason:
A weak urinary stream is appropriate. Benign prostatic hyperplasia (BPH) is a common condition in older men characterized by noncancerous enlargement of the prostate gland, which can lead to compression of the urethra and urinary symptoms. A weak urinary stream is a classic symptom of BPH due to the obstruction caused by the enlarged prostate gland, which interferes with the normal flow of urine. Therefore, the nurse should expect a weak urinary stream as an additional finding during the client interview, which is consistent with the suspected diagnosis of BPH.
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