The practical nurse (PN) learns in report that a client has jugular vein distention (JVD). Which technique should the PN use to confirm this finding?
Inspection.
Palpation.
Auscultation.
Percussion.
The Correct Answer is A
A. Inspection: Jugular vein distention is assessed visually with the client positioned at a 30–45° angle. Observation of the jugular veins provides information about central venous pressure and fluid status.
B. Palpation: Palpating the jugular vein is not recommended because it can cause discomfort and may collapse the vein, making assessment inaccurate. Visual inspection is preferred.
C. Auscultation: Listening with a stethoscope is not used to assess JVD. Auscultation is more appropriate for evaluating heart or lung sounds rather than vein distention.
D. Percussion: Percussion is not effective for assessing jugular vein distention. This technique is used to evaluate underlying structures in the chest or abdomen, not superficial vein distention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clonidine: Clonidine, an alpha-2 agonist, can cause side effects such as drowsiness, dry mouth, and rebound hypertension if discontinued abruptly. A persistent dry cough is not commonly associated with clonidine.
B. Quinapril: Quinapril is an ACE inhibitor, and a persistent dry cough is a well-known side effect due to accumulation of bradykinin in the respiratory tract. Clients taking ACE inhibitors should be monitored for this symptom, which may necessitate medication adjustment.
C. Spironolactone: Spironolactone is a potassium-sparing diuretic. Common side effects include hyperkalemia, gynecomastia, and menstrual irregularities, but it is not typically associated with a persistent dry cough.
D. Losartan: Losartan is an angiotensin receptor blocker (ARB) and generally does not cause cough. It is often prescribed as an alternative to ACE inhibitors for clients who experience cough.
Correct Answer is A
Explanation
A. Visible or audible separation anxiety: Searching for a fallen toy indicates that the infant has developed object permanence, a concept from Piaget’s sensorimotor stage (typically around 8–12 months). At this stage, infants begin to understand that people and objects continue to exist even when out of sight, leading to visible signs of separation anxiety.
B. Exploration beyond caregiver presence: This occurs later in toddlerhood, during the preoperational stage, when children develop greater autonomy and confidence. Infants with newly developed object permanence still rely heavily on the caregiver’s presence for security and comfort.
C. Comprehension of simple commands: Understanding and responding to simple verbal directions usually emerge after the first year of life, as language and cognitive skills advance beyond the early sensorimotor period. It is not associated with the stage of object permanence.
D. Ability to place objects in a container: This fine motor milestone develops slightly later, closer to 12–15 months, when hand-eye coordination improves. It reflects motor development rather than a specific cognitive milestone of object permanence.
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