The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Listen to the heart sounds using the bell of a stethoscope.

Use a Doppler ultrasound to hear the heartbeat.

Obtain a pulse oximeter reading from two extremities.

Auscultate for one minute with the stethoscope's diaphragm.

Answer and Explanation

The Correct Answer is A

A.   The bell of the stethoscope is best for detecting low-pitched sounds like murmurs or extra heart sounds.
B.   A Doppler ultrasound is not necessary for routine auscultation of heart sounds.
C.   Pulse oximetry does not provide relevant information about heart sounds.
D.   Auscultating with the diaphragm is better for high-pitched sounds, so the bell is preferred for extra heart sounds.

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Correct Answer is D

Explanation

A. A hematoma refers to a collection of blood outside of blood vessels, typically resulting in a bruise or swelling. The description of round, flat, pinpoint red spots does not suggest this type of injury.
B. Vesicles are small fluid-filled blisters, which do not match the description of the pinpoint red spots. Vesicles would be more elevated and contain fluid.
C. Ecchymosis refers to a bruise, or large, irregular areas of discoloration caused by blood leaking into the tissues. The description of pinpoint red spots suggests petechiae, not ecchymosis.
D. Petechiae are small, round, flat, pinpoint red or purple spots that occur when small blood vessels (capillaries) break under the skin. This is the most appropriate description for the observed finding, particularly in the context of trauma from intimate partner violence.

A. Examine client's sclera for icterus. B. Review recent serum bilirubin levels. C. Observe the client's urine for dark orange color. D. Assess conjunctival sacs of lower lids for pallor.

Correct Answer is A

Explanation

A. Icterus, or yellowing of the sclera, is a key sign of jaundice, which occurs when there is an excess of bilirubin in the blood.
B. Serum bilirubin levels are important for diagnosis but are not an immediate physical assessment.
C. Dark urine can suggest liver or bile duct issues but is not definitive for jaundice.
D. Pallor of the conjunctiva indicates anemia, not jaundice.

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The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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