The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

Listen for abnormal sounds.

Identify S1 and S2 heart sounds.

Move the stethoscope to the apical site.

Change to the bell of the stethoscope.

Answer and Explanation

The Correct Answer is B

A. Listen for abnormal sounds. Before identifying abnormal sounds, it's essential to first establish a baseline by identifying the normal heart sounds (S1 and S2).

B. Identify S1 and S2 heart sounds. This is the correct first step in a systematic assessment of heart sounds. S1 ("lub") corresponds to the closure of the atrioventricular valves (mitral and tricuspid), while S2 ("dub") corresponds to the closure of the semilunar valves (aortic and pulmonic).

C. Move the stethoscope to the apical site. While the apical site is important for auscultating specific heart sounds, it's best to first identify S1 and S2 at the traditional auscultatory areas (aortic, pulmonic, tricuspid, and mitral).

D. Change to the bell of the stethoscope. The bell of the stethoscope is used to listen for lower-pitched sounds, but it's not typically used for identifying S1 and S2 heart sounds, which are higher-pitched.

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Correct Answer is C

Explanation

A. Functional capacity: While important for older adults, it's not the most pressing concern during this routine follow-up exam.

B. Distinguishing symptoms: This is an ongoing process, but not the most critical element for this visit.

C. Obtain a medication history including prescription and non-prescription drugs. Cataract surgery often involves medication changes or new medications to prevent infection or manage other post-operative needs. An updated medication history helps identify potential interactions or side effects.

D. Advance directives: While important for all adults, it might not be the most urgent topic for this specific follow-up exam focused on managing existing conditions and potential post-surgical medications.

A. Pupils equal, round, reacts to light (PERRL) B. Pupils equal, round, reacts to light, and accommodation (PERLA) C. Neurological status intact. D. Glasgow Coma Scale (GCS) of 15.

Correct Answer is A

Explanation

A. Pupils equal, round, reacts to light (PERRL) This notation accurately reflects the observed findings.

B. Pupils equal, round, reacts to light, and accommodation (PERLA) While it includes accommodation, there was no specific assessment of accommodation mentioned.

C. Neurological status intact. This is too vague and does not provide specific details about the pupils.

D. Glasgow Coma Scale (GCS) of 15. The GCS score indicates overall neurological function, not specific pupil findings.

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The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Correct Answer is A

Explanation

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