The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Dependent edema

Stasis ulceration

Arterial occlusion

Venous insufficiency

Answer and Explanation

The Correct Answer is D

A. Dependent edema is characterized by swelling in the lower extremities due to gravity and may not always present with pigmentation changes.

B. Stasis ulceration involves ulcerative lesions typically occurring on the lower legs, often associated with venous insufficiency, but the pigmentation alone does not confirm ulceration.

C. Arterial occlusion typically presents with symptoms such as pain, pallor, and decreased pulses, not necessarily with warm skin and brown pigmentation.

D. Venous insufficiency is characterized by symptoms such as warm skin, brown pigmentation around the ankles (due to hemosiderin deposition from blood pooling), and swelling.

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Correct Answer is D

Explanation

A. Gallops refer to abnormal heart sounds that occur during the cardiac cycle, not typically associated with sounds over the carotid artery.

B. Murmurs are abnormal heart sounds that occur due to turbulent blood flow in the heart, not typically related to the carotid artery.

C. Normal findings would not usually include high-pitched swooshing sounds over the carotid artery; such sounds are abnormal.

D. Bruits are abnormal sounds caused by turbulent blood flow in the arteries, which can be detected as high-pitched swooshing sounds over the carotid artery, often indicative of stenosis or narrowing of the vessel.

A. Percuss, inspect, auscultate, palpate B. Auscultate, inspect, palpate, percuss C. Palpate, percuss, inspect, auscultate D. Inspect, auscultate, percuss, palpate

Correct Answer is D

Explanation

A. Percuss, inspect, auscultate, palpate: This sequence is incorrect because inspection should be performed first to assess the abdomen visually.

B. Auscultate, inspect, palpate, percuss: This sequence is incorrect because auscultation should follow inspection and before palpation and percussion.

C. Palpate, percuss, inspect, auscultate: This sequence is incorrect as palpation and percussion should not come before inspection.

D. Inspect, auscultate, percuss, palpate: This is the correct sequence. Inspection is first, followed by auscultation to listen to bowel sounds, then percussion to assess for fluid or gas, and finally palpation to check for tenderness or masses.

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The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

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Naxlex Comprehensive Predictor Exams

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

Correct Answer is D

Explanation

A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Correct Answer is D

Explanation

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