The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

The jugular venous pulse is visible when the client lies supine.

The jugular veins are distended when the client sits at a 45-degree angle.

The jugular venous pulse is not visible when the client is sitting upright.

The jugular veins are fully distended when the client is in a high Fowler position.

Answer and Explanation

The Correct Answer is C

Choice A reason: Visible jugular pulse supine is normal, as gravity pools venous blood. However, the question seeks upright findings. This is expected lying down, not sitting, misaligning with the healthy standard for an upright position in this context fully.

Choice B reason: Distended jugular veins at 45 degrees suggest elevated central venous pressure, like in heart failure, not health. In a healthy client, veins collapse at this angle, making this an abnormal, not expected, finding for jugular assessment here.

Choice C reason: No visible jugular pulse upright is normal in health, as venous pressure drops below the clavicle when sitting. This reflects proper heart function and gravity’s effect, aligning with expected findings in a healthy client’s neck vessel exam accurately.

Choice D reason: Full jugular distension in high Fowler’s (60-90 degrees) indicates pathology, like right heart failure, not health. Healthy veins collapse at this elevation, making this an abnormal finding, not the expected norm for jugular assessment entirely here.

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Correct Answer is A

Explanation

Choice A reason: Tonsils touching the uvula indicate 4+ grading, where they obstruct over 75% of the oropharynx. This severe enlargement, with sore throat, fits the highest scale, reflecting significant inflammation or infection impacting airway and swallowing, accurately documented here.

Choice B reason: 1+ tonsils are slightly enlarged, less than 25% of the oropharynx, visible but not near the uvula. This underestimates the finding of tonsils contacting the uvula, misrepresenting the degree of obstruction and inflammation present in this case entirely.

Choice C reason: 2+ tonsils occupy 25-50% of the oropharynx, not touching the uvula. This moderate grade doesn’t match the observed contact, understating the severity of enlargement and potential airway compromise noted during the inspection clearly and significantly.

Choice D reason: 3+ tonsils cover 50-75% of the oropharynx, nearing but not contacting the uvula. This is close but inaccurate, as the finding shows full contact, warranting the higher 4+ grade for precise documentation of this advanced tonsillar size fully.

A. Do you have a history of chronic rhinitis? B. Have you been prescribed immunosuppressive therapy? C. How often do you usually go to the dentist in a year? D. Do you have any difficulty chewing or swallowing?

Correct Answer is B

Explanation

Choice A reason: Chronic rhinitis affects nasal passages, not oral cancer risk, which ties to tobacco, alcohol, or HPV. This question targets sinus issues, missing key carcinogenic exposures or immunosuppression linked to squamous cell carcinoma in the mouth entirely here.

Choice B reason: Immunosuppressive therapy, like post-transplant drugs, raises oral cancer risk by impairing immune surveillance against HPV or malignant cells. This directly identifies a major risk factor, aligning with health promotion goals to detect oral cancer precursors effectively and accurately.

Choice C reason: Dental visit frequency reflects care access, not specific oral cancer risks like smoking. It’s indirect, missing direct links to immunosuppression or carcinogens, making it less effective for pinpointing etiology in a health promotion context fully here.

Choice D reason: Chewing or swallowing difficulty may signal advanced cancer, not risk factors. It’s a symptom, not a preventive focus, unlike immunosuppression, which precedes disease, reducing its utility for early identification in this educational assessment entirely and clearly.

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The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is integrating health promotion education into the assessment of a client's mouth, nose and throat. What interview question is most likely to identify a risk factor for oral cancer?

Correct Answer is B

Explanation

The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow up?

While inspecting the tympanic membrane the nurse notes a pearly gray and shiny appearance. What would this finding indicate?

A client is admitted to the emergency room with a head injury. The client denies a previous history of seizures or head injury. What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

A health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients on how to clean their ears, what action should the nurse recommend?

The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

The client reports a decreased sense of smell for the past week. Which condition would the nurse assess for?