The nurse is assessing the carotid arteries of a client with cardiovascular disease. What action should be performed next by the nurse?

Discuss that a light will be directed at the neck to observe for pulsations of the artery

instruct the client to take a deep breath and "hold" while the nurse briefly auscultates

Demonstrate that both arteries will be palpated simultaneously to compare amplitude

Show the client the diaphragm of the stethoscope that will be placed on the neck

Answer and Explanation

The Correct Answer is C

A. Discuss that a light will be directed at the neck to observe for pulsations of the artery:

This choice is incorrect. Directing light at the neck is not a standard method for assessing carotid artery pulsations. The carotid artery is usually assessed by palpation to feel the pulse rather than visual observation.

B. Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates:

This choice is incorrect. Auscultation is typically not used to assess carotid artery pulsations. Palpation (feeling the pulse) is the primary method used for this assessment.

C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude:

This choice is correct. Palpating both carotid arteries simultaneously allows the nurse to compare the amplitude (strength) of the pulses. This comparison helps in assessing the symmetry of the pulses and ensures there are no significant differences between the two sides, which could indicate vascular abnormalities.

D. Show the client the diaphragm of the stethoscope that will be placed on the neck:

This choice is incorrect. The diaphragm of the stethoscope is not typically used for palpating pulses. Palpation involves using the fingertips to feel the pulse and assess its strength and regularity.

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Correct Answer is A

Explanation

A. Continue with the assessment, looking for any other abnormal findings: This is the correct response. Tonsils in adults can have various appearances, and a granular appearance with deep crypts is within the range of normal. It's essential for the nurse to continue the assessment and observe for other signs or symptoms that might indicate an issue.

B. Refer the patient to a throat specialist: Referring the patient based solely on the appearance of the tonsils, especially if it's a normal variant, might be unnecessary and could cause undue concern for the patient. It's important to assess the patient comprehensively before considering a specialist referral.

C. No response is needed; this appearance is normal for the tonsils: This is the correct explanation. In adults, tonsils often appear granular with deep crypts, which is considered a normal variation. No further action is required regarding the tonsils.

D. Obtain a throat culture on the patient for possible streptococcal (strep) infection: Based on the description provided (involution, granular appearance, and deep crypts), there's no specific indication of a streptococcal infection. Conducting a throat culture should be based on the presence of specific symptoms and signs indicative of a streptococcal infection, such as sore throat, fever, and swollen tonsils with white patches, rather than just the appearance of the tonsils.

A. The atria contract toward the end of diastole and push the remaining blood into the ventricles. B. The atria contract during systole and attempt to push against closed valves. C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole. D. Contraction of the atria at the beginning of diastole can be felt as a palpitation.

Correct Answer is A

Explanation

A. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

This choice is correct. During atrial systole (atrial contraction), the atria contract, pushing the remaining blood into the ventricles. This additional filling of the ventricles optimizes cardiac output.

B. The atria contract during systole and attempt to push against closed valves.

This statement is incorrect. The atria do not contract during systole; they contract during diastole (atrial systole) to fill the ventricles.

C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.

This statement is incorrect. Atrial kick refers to the atrial contraction, not the pressure exerted against the atria.

D. Contraction of the atria at the beginning of diastole can be felt as a palpitation.

This statement is not entirely accurate. A palpitation is a sensation of rapid or strong heartbeat, which might be felt during various cardiac events, not specifically during atrial contraction at the beginning of diastole.

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The nurse is assessing the carotid arteries of a client with cardiovascular disease. What action should be performed next by the nurse?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the tonsils of an adult client. The nurse notices that the tonsils are involuted, granular in appearance, and has deep crypts. The nurse recognizes that which of the following is the correct response to these findings?

Correct Answer is A

Explanation

A nurse is reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

Correct Answer is A

Explanation

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