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The nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmurs (S3, S4)

Breath sounds

Normal heart (S1,S2)

Bowel sounds

Answer and Explanation

The Correct Answer is A

A. The bell of the stethoscope is used to detect low-pitched sounds such as heart murmurs (S3 and S4).

B. Breath sounds are typically auscultated using the diaphragm of the stethoscope.

C. Normal heart sounds (S1, S2) are best heard using the diaphragm of the stethoscope.

D. Bowel sounds are auscultated using the diaphragm, not the bell.

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Correct Answer is D

Explanation

A. Asking the client to swallow assesses the glossopharyngeal and vagus nerves.

B. Eliciting the gag reflex also assesses the glossopharyngeal and vagus nerves.

C. Testing visual acuity assesses the optic nerve.

D. The oculomotor nerve (cranial nerve III) controls pupillary response and eye movement, so the nurse should assess the pupillary response to light.

A. Pale yellow urine B. Flat neck veins C. Hypotension D. Poor skin turgor E. Bradycardia

Correct Answer is ["B","C","D"]

Explanation

A. Pale yellow urine would not be expected, as dehydration often leads to concentrated, dark urine.

B. Flat neck veins are a sign of dehydration and decreased fluid volume.

C. Hypotension is expected with dehydration due to a drop in circulating blood volume.

D. Poor skin turgor is a common indicator of dehydration as the skin loses elasticity.

E. Bradycardia is not expected; rather, tachycardia is more common in dehydration as the body tries to compensate for fluid loss.

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The nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client on the neurologic medical-surgical unit who was admitted for a new onset of cerebrovascular attack. The client has a medical history of hypertension and diabetes. While conducting a neurologic assessment, how should the nurse assess the oculomotor nerve?

Correct Answer is D

Explanation

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Correct Answer is ["B","C","D"]

Explanation

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