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. Technician B. Secretary C. Nurse D. Physician

Correct Answer is C

Explanation

A. Technician: Technicians generally perform specific tasks or tests rather than collecting comprehensive subjective data.

B. Secretary: A secretary's role is administrative and does not involve direct patient assessment or data collection.

C. Nurse: Nurses are typically responsible for collecting subjective data from clients during the initial comprehensive assessment, including patient history and current health concerns.

D. Physician: While physicians review and interpret data, they often rely on nurses to collect detailed subjective information during initial assessments.

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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?

Nursing Test Bank

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

Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?

Correct Answer is C

Explanation

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