When auscultating over a patient's femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits:
Occur in the presence of lymphadenopathy.
Occur with turbulent blood flow, indicating partial occlusion.
In the femoral arteries are caused by hypermetabolic states.
Are often associated with venous disease.
The Correct Answer is B
A. Lymphadenopathy: A bruit is not associated with lymphadenopathy; it is caused by turbulent blood flow.
B. Turbulent blood flow: A bruit is the sound of turbulent blood flow, which occurs due to partial arterial occlusion.
C. Hypermetabolic states: While bruits can be heard in various conditions, they are not typically associated with hypermetabolic states like fever or thyroid disease.
D. Venous disease: Bruits are arterial in origin, not related to venous disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Shield the lips: Shielding the lips ensures the patient is not lip-reading but should not muffle the sound.
B. Whisper random numbers and letters: The whisper test involves standing behind the patient, whispering a series of numbers and letters, and asking the patient to repeat them.
C. Occlude outside noise: Asking the patient to occlude one ear may alter test results.
D. Stand approximately 4 feet away: The whisper test is typically performed from 1-2 feet behind the patient.
Correct Answer is A
Explanation
A. Shine a light across the pupil from the side: To assess the pupillary light reflex, the nurse should shine a light across the pupil from the side and observe for both direct and consensual constriction (the constriction of both pupils when one is exposed to light).
B. Follow the penlight: This tests for accommodation (focusing on near objects) rather than the pupillary light reflex.
C. Shine a penlight directly in front: This method doesn’t assess both direct and consensual constriction properly.
D. Focus on a distant object: This assesses accommodation, not the pupillary light reflex.
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