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. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

A. It filters harmful substances from the body. B. It drains capillary blood from the circulation. C. It produces protective antibodies. D. It manufactures T lymphocytes.

Correct Answer is A

Explanation

A. It filters harmful substances from the body: The lymphatic system plays a crucial role in filtering lymph fluid and removing harmful substances, such as pathogens and toxins, through lymph nodes.

B. It drains capillary blood from the circulation: The lymphatic system does not directly drain capillary blood; instead, it collects interstitial fluid and returns it to the bloodstream.

C. It produces protective antibodies: Antibodies are produced by B lymphocytes in the immune system, not directly by the lymphatic system itself.

D. It manufactures T lymphocytes: While the lymphatic system is involved in the maturation and function of T lymphocytes, their manufacture occurs in the bone marrow and thymus rather than the lymphatic system itself.

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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

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Explanation

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Correct Answer is A

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