Patient Data

Exhibits

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":"E","dropdown-group-2":"B"}

S1 (First Heart Sound): Loudest at the apex of the heart, which is located at the 5th intercostal space, midclavicular line. It is caused by the closure of the mitral and tricuspid valves.

S2 (Second Heart Sound): Loudest at the base of the heart, which is located at the 2nd intercostal space, near the aortic and pulmonic areas. It is produced by the closure of the aortic and pulmonic valves.

Center of the heart. No major auscultation point is located in the center. The heart sounds are best heard where blood flow is directed against the chest wall, not in the middle of the thorax.

Left side of the heart. While the left heart contains the mitral and aortic valves, this is too vague.The mitral sound (S1) is best heard at the apex, while the aortic sound (S2) is best heard at the base.

Right side of the heart. The tricuspid and pulmonic valves are on the right, but heart sounds are best heard at specific points rather than the general right side.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ask the client about any localized tenderness at the site. Enlarged lymph nodes can indicate infection, inflammation, or malignancy. Assessing for tenderness helps differentiate between reactive lymphadenopathy (which is often tender) and potentially more concerning causes like malignancy (which is usually non-tender and hard).

B. Auscultate the lymph node for the presence of a bruit. Lymph nodes do not typically produce bruits. If a bruit is suspected, the nurse should auscultate the carotid artery or consider the possibility of an abnormal vascular structure, such as an arteriovenous malformation.

C. Record this normal finding in the assessment record. While small, non-tender lymph nodes can sometimes be normal, an enlarged, visible lymph node is not considered a normal finding and requires further assessment.

D. Cover the inflamed area and notify the healthcare provider. Lymph node enlargement does not require covering unless there is an open wound or drainage. While notifying the provider may be necessary in some cases, further assessment is the priority before escalation.

A. Multiple maculopapular pustules over forehead and chin on an adolescent. B. Bilateral patellar abrasions with eschar formation on a preschool-aged child. C. Red, swollen, painful nodule located on upper back on a school-aged boy. D. Small, white flecks on the hair shafts throughout scalp on a school-aged girl.

Correct Answer is C

Explanation

A. Multiple maculopapular pustules over forehead and chin on an adolescent. This description is consistent with acne vulgaris, a common skin condition in adolescents due to hormonal changes. While acne may require treatment, it is not an urgent finding that requires immediate reporting.

B. Bilateral patellar abrasions with eschar formation on a preschool-aged child. Abrasions with eschar (scab) formation suggest healing skin injuries, likely from minor falls or play-related trauma. This is a normal finding in active children and does not require urgent reporting.

C. Red, swollen, painful nodule located on upper back on a school-aged boy. This finding is consistent with a skin abscess or possibly a MRSA (methicillin-resistant Staphylococcus aureus) infection, which may require antibiotics or incision and drainage. The presence of pain, swelling, and redness suggests an active infection that should be evaluated by a healthcare provider.

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Patient Data Exhibits Heart sounds are loudest for S1 at the dropdown and for S2 at the dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Correct Answer is A

Explanation

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

Correct Answer is C

Explanation

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years? (Enter the numerical value only.)

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Patient Data

Exhibits

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