In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Left carotid artery has strong pulse; right carotid artery occluded.

Left carotid pulse volume of 4+; right carotid pulse volume of 0.

Left carotid artery occlusion present; no occlusion of right carotid artery.

Left carotid artery bruit present; no bruit heard in right carotid artery.

Answer and Explanation

The Correct Answer is D

A) Left carotid artery has strong pulse; right carotid artery occluded:
This documentation is incorrect because the presence of a bruit does not indicate a strong pulse or occlusion. A bruit suggests turbulent blood flow, often due to partial obstruction or narrowing of the artery, not necessarily a strong pulse or complete occlusion.

B) Left carotid pulse volume of 4+; right carotid pulse volume of 0:
This documentation focuses on the pulse volume rather than the presence of a bruit. The nurse's assessment was related to auscultation findings (bruit) rather than palpation findings (pulse volume).

C) Left carotid artery occlusion present; no occlusion of right carotid artery:
A bruit indicates turbulent blood flow, which may be due to partial obstruction, but it does not confirm complete occlusion. Therefore, this documentation would be inaccurate.

D) Left carotid artery bruit present; no bruit heard in right carotid artery:
This documentation accurately reflects the nurse's findings. A bruit is a blowing, swishing sound indicating turbulent blood flow, often due to narrowing or partial obstruction of the artery. Documenting the presence of a bruit provides essential information for further evaluation and management.

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Correct Answer is D

Explanation

Answer: D

Rationale:

A) Tenderness:

Tenderness upon palpation is not considered a normal finding. It may indicate inflammation, injury, or other underlying conditions affecting the thoracic region. Tenderness requires further investigation to determine the cause and appropriate treatment.

B) Crepitus:

Crepitus, which is a crackling or popping sensation felt under the skin, is not a normal finding. It can be associated with subcutaneous air or gas, often resulting from trauma or infection. Identifying crepitus prompts further evaluation to determine the underlying issue.

C) Thrill:

A thrill is a palpable vibration or sensation over the chest, typically felt over an area of turbulent blood flow, such as a heart murmur. It is not considered a normal finding in the thoracic region and usually indicates an abnormal cardiovascular condition that requires further assessment.

D) Non-tender:

A non-tender thoracic region is considered a normal finding. Absence of tenderness upon palpation indicates no immediate signs of inflammation or injury in the thoracic area, suggesting that the palpation findings are within the expected range of normal physical examination.

A. Deep, continuous pain in the calf muscles. B. Painful symptoms alleviated by warmth. C. Cool, pale skin below the knees. D. Decreased pain when legs are elevated.

Correct Answer is D

Explanation

A. Deep, continuous pain in the calf muscles:
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

B. Painful symptoms alleviated by warmth:
Painful symptoms alleviated by warmth are more characteristic of arterial insufficiency, such as in peripheral arterial disease (PAD), rather than venous insufficiency.

C. Cool, pale skin below the knees:
Cool, pale skin below the knees is also more suggestive of arterial insufficiency rather than venous insufficiency. Arterial insufficiency often presents with decreased blood flow to the extremities, resulting in coolness and pallor.

D. Decreased pain when legs are elevated:
This is the correct answer. Venous insufficiency typically results in symptoms such as aching, tired legs, and swelling, which worsen with prolonged standing but improve with leg elevation. This is due to the reduction in venous pressure when the legs are elevated, which helps alleviate symptoms associated with venous congestion and stasis.

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In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Correct Answer is D

Explanation

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Correct Answer is D

Explanation

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