What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?
Simultaneously palpate both arteries to compare amplitude.
Instruct the patient to take slow deep breaths during auscultation.
Compress the artery in the upper one-third of the neck while listening with the diaphragm of a stethoscope.
Listen with the bell of the stethoscope to assess for bruits.
The Correct Answer is D
Choice A reason: Simultaneously palpating both carotid arteries is dangerous, risking reduced cerebral blood flow, especially in cardiovascular patients. Using the bell to listen for bruits is safer, so this is incorrect.
Choice B reason: Deep breaths are for lung auscultation, not carotid, where patients hold breath to reduce noise. The bell detects low-pitched bruits, so instructing deep breaths is incorrect for carotid assessment.
Choice C reason: Compressing the carotid artery risks reducing blood flow or dislodging plaques, which is unsafe. Listening with the bell for bruits is the standard method, so this is incorrect.
Choice D reason: Listening with the bell of the stethoscope detects low-frequency bruits, indicating carotid artery narrowing, which is critical in cardiovascular disease. This is the correct technique for safe assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Costovertebral angle tenderness is a classic sign of pyelonephritis, indicating kidney infection or inflammation. Percussing this area elicits pain in renal conditions, making it the correct condition to assess for tenderness.
Choice B reason: Cholecystitis causes pain in the right upper quadrant, not the costovertebral angle. Kidney-related pyelonephritis is linked to this tenderness, so this is incorrect for the assessment focus.
Choice C reason: Gastric ulcers cause epigastric pain, not costovertebral tenderness, which is renal-specific. Pyelonephritis is the condition associated with this sign, so this is incorrect for the suspected condition.
Choice D reason: Pancreatitis presents with abdominal pain, not costovertebral angle tenderness, which indicates kidney issues. Pyelonephritis is the relevant condition, so this is incorrect for the assessment.
Correct Answer is B
Explanation
Choice A reason: Herniated brainstem causes bilateral pupil changes and severe neurological signs, not unilateral dilation. Unilateral pupil dilation suggests increased intracranial pressure, so this is incorrect for these findings.
Choice B reason: Unilateral pupil dilation and nonreactivity, as seen in the right pupil, indicate increased intracranial pressure, often from mass effect compressing the oculomotor nerve. This is critical, making it the correct finding.
Choice C reason: Subdural hemorrhage may cause pressure but isn’t specific to these pupil changes. Unilateral dilation points to increased intracranial pressure as the immediate concern, so this is less precise.
Choice D reason: Cerebral edema contributes to pressure but is a broader term. Unilateral pupil dilation specifically suggests increased intracranial pressure, a more immediate and precise diagnosis, so this is incorrect.
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