The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?
Murmurs.
Absent sounds.
No adventious sounds.
Adventious sounds.
The Correct Answer is C
A. While some older adults may have physiologic or benign murmurs, murmurs are not considered universally normal and require further assessment to rule out pathology.
B. Absent heart sounds would be abnormal and could indicate severe underlying issues such as cardiac arrest or severe hypovolemia.
C. A normal heart auscultation in an older adult includes S1 and S2 heart sounds without extra or abnormal sounds. While some older adults may develop benign murmurs due to age-related changes in valve structure, the absence of abnormal or adventitious sounds (such as S3, S4, or pathological murmurs) is considered a normal finding.
D. Adventitious sounds (such as crackles or wheezes) are not normal in heart auscultation and would suggest potential pathologies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fluid replacement is crucial to prevent dehydration and maintain electrolyte balance, which is vital in clients with severe ulcerative colitis and after surgery.
B. Turning the client is important to prevent pressure ulcers but is not as immediately critical as fluid balance.
C. Recording wound drainage is necessary but secondary to ensuring the client’s fluid and electrolyte status.
D. Assessing skin condition is important but fluid balance takes priority in this scenario.
Correct Answer is D
Explanation
A. Assisting with giving sips of water could pose a choking risk if the client's swallowing ability is impaired.
B. Using a straw could increase the risk of aspiration for a client with swallowing difficulties.
C. Obtaining thickening powder might be necessary, but first the nurse must assess the client's ability to swallow safely.
D. Assessing the client's swallowing reflex is the priority to ensure safe swallowing and prevent aspiration.
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