The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

S4 heart sound

Harsh holosystolic murmur at the apex

S3 heart sound

Carotid bruits

Answer and Explanation

The Correct Answer is C

A. S4 heart sound: An S4 heart sound is often associated with hypertensive heart disease or left ventricular hypertrophy, rather than congestive heart failure alone.

B. Harsh holosystolic murmur at the apex: This type of murmur is more indicative of mitral regurgitation rather than congestive heart failure.

C. S3 heart sound: An S3 heart sound is commonly associated with congestive heart failure, especially when there is volume overload and decreased left ventricular function.

D. Carotid bruits: Carotid bruits are associated with vascular issues rather than congestive heart failure.

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Correct Answer is C

Explanation

A. XII: Cranial nerve XII (hypoglossal) controls tongue movements, but is not typically assessed by the technique described.

B. V: Cranial nerve V (trigeminal) is assessed for facial sensation and mastication, not the technique in question.

C. VII: Cranial nerve VII (facial) is responsible for facial expressions and is assessed by asking the client to perform various facial movements.

D. XI: Cranial nerve XI (accessory) is involved in shoulder and neck movements, not facial expressions.

A. Wait until the end of the physical assessment to reassess the radial pulse. B. Reassess the client's pedal pulse on the other foot. C. Assess the client's 51 and 52 sounds for regularity. D. Assess the client's apical pulse for a full minute.

Correct Answer is ["A","D"]

Explanation

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

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The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

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Naxlex Comprehensive Predictor Exams

The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

Correct Answer is C

Explanation

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

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