When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Multiple yellow lesions with a grainy surface.

Large, flat, dark red irregular area on the neck.

Bluish discoloration of the nail beds.

Multiple silver striae on the abdomen

Answer and Explanation

The Correct Answer is C

A. Multiple yellow lesions with a grainy surface. These could indicate xanthomas, which are associated with lipid disorders and may warrant further investigation and treatment.

B. Large, flat, dark red irregular area on the neck. This could be a port-wine stain, which is typically a congenital condition and may not require immediate medical intervention unless associated with other symptoms.

C. Bluish discoloration of the nail beds. This indicates cyanosis, which can be a sign of hypoxia or cardiovascular issues. It requires prompt evaluation by a healthcare provider to determine the underlying cause and necessary interventions.

D. Multiple silver striae on the abdomen. Striae, or stretch marks, are usually benign and often result from rapid weight changes or hormonal variations. They typically do not require immediate medical attention.

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Correct Answer is "{\"xRanges\":[56.109375,86.109375],\"yRanges\":[109,139]}"

Explanation

To auscultate for the presence of a carotid artery bruit, the nurse should place the bell of the stethoscope over the carotid artery. Specifically, the nurse should place the bell of the stethoscope lightly on the skin just medial to the sternocleidomastoid muscle at the level of the thyroid cartilage. The carotid artery can be found in the neck, just lateral to the trachea and medial to the sternocleidomastoid muscle.

A. Listen for abnormal sounds. B. Identify S1 and S2 heart sounds. C. Move the stethoscope to the apical site. D. Change to the bell of the stethoscope.

Correct Answer is B

Explanation

A. Listen for abnormal sounds. Before identifying abnormal sounds, it's essential to first establish a baseline by identifying the normal heart sounds (S1 and S2).

B. Identify S1 and S2 heart sounds. This is the correct first step in a systematic assessment of heart sounds. S1 ("lub") corresponds to the closure of the atrioventricular valves (mitral and tricuspid), while S2 ("dub") corresponds to the closure of the semilunar valves (aortic and pulmonic).

C. Move the stethoscope to the apical site. While the apical site is important for auscultating specific heart sounds, it's best to first identify S1 and S2 at the traditional auscultatory areas (aortic, pulmonic, tricuspid, and mitral).

D. Change to the bell of the stethoscope. The bell of the stethoscope is used to listen for lower-pitched sounds, but it's not typically used for identifying S1 and S2 heart sounds, which are higher-pitched.

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When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?

Correct Answer is "{\"xRanges\":[56.109375,86.109375],\"yRanges\":[109,139]}"

Explanation

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

Correct Answer is B

Explanation

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