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

Left carotid artery bruit present; bruit heard in right carotid artery.

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

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

Answer and Explanation

The Correct Answer is B

Choice A rationale
The description of pulse volume (4+ and 0) is not appropriate for documenting a bruit. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, not pulse volume.
Choice B rationale
A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis. The presence of a bruit in the left carotid artery and the absence of sound in the right carotid artery should be documented as such.
Choice C rationale
While a bruit can indicate partial occlusion of an artery, it does not confirm complete occlusion. Complete occlusion would typically result in the absence of blood flow and no sound. Therefore, this choice is incorrect.
Choice D rationale
The presence of a bruit does not necessarily indicate a strong pulse. It indicates turbulent blood flow, which is often due to narrowing or partial blockage of the artery. This choice is incorrect

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Correct Answer is D

Explanation

Choice A rationale
Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation.
Choice B rationale
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions, but the presence of a depressed umbilicus does not necessarily indicate scarring or previous surgery.
Choice C rationale
Asking about recent abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, but it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen.
Choice D rationale
A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.

A. Recent over-the-counter infection cures. B. Number of indoor cats at home. C. Nontender firm lymph nodes. D. Amount of daily caffeine consumption.

Correct Answer is C

Explanation

Choice C rationale
Nontender firm lymph nodes are a significant finding that may indicate a more serious underlying condition, such as malignancy. This information is crucial for the healthcare provider to determine the next steps in diagnosis and treatment.
Choice A rationale
Recent over-the-counter infection cures are less relevant compared to the physical characteristics of the lymph nodes when assessing for potential malignancy.
Choice B rationale
The number of indoor cats at home is not directly related to the assessment of enlarged lymph nodes in the axilla.
Choice D rationale
The amount of daily caffeine consumption is not relevant to the assessment of enlarged lymph nodes in the axilla.

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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

During assessment of a client’s abdomen, the nurse observes that the client’s umbilicus is depressed and below the surface of the abdomen.Which action should the nurse take in response to this observation?

Correct Answer is D

Explanation

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Correct Answer is C

Explanation

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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?

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?