When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Aortic site.

Sternum.

Lung apex.

Clavicle.

Answer and Explanation

The Correct Answer is C

A) Aortic site:
The aortic site is relevant for cardiac assessment but not for auscultating breath sounds.

B) Sternum:
The sternum is a bony structure and not an optimal location to start auscultating breath sounds as it can interfere with sound transmission.

C) Lung apex:
Auscultating at the lung apex, which is located just above the clavicle, is the appropriate starting point for assessing anterior breath sounds. This ensures that the upper parts of the lungs are examined first.

D) Clavicle:
While the area near the clavicle is relevant, it is more precise to refer to the lung apex, which includes the area just above the clavicle, for starting the auscultation of breath sounds.

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Correct Answer is B

Explanation

A) Retracted and non-mobile tympanic membrane: This finding is typically associated with conditions such as eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described in this scenario.

B) Red, edematous ear canal with no visualization of the tympanic membrane: This description aligns with otitis externa, commonly known as "swimmer's ear." The client's history of recent swimming, itching, pain, and discharge with a musty odor are classic signs of this condition. In otitis externa, the ear canal often appears red and swollen, and the inflammation can obstruct the view of the tympanic membrane.

C) Translucent, pearly gray and mobile tympanic membrane: This appearance indicates a normal, healthy ear and is inconsistent with the symptoms of pain, itching, and discharge described by the client.

D) Thickened and bulging tympanic membrane: This finding is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum, causing it to bulge. However, it does not match the scenario of external ear canal inflammation and discharge following swimming.

A. Palpate dorsal surface of feet for warmth. B. Test feet for a positive Babinski reflex. C. Measure skin elasticity around the ankles. D. Assess volume of the pedal pulses. E. Observe color of the feet and toes.

Correct Answer is ["A","D","E"]

Explanation

A) Palpate dorsal surface of feet for warmth:
Assessing the temperature of the dorsal surface of the feet helps determine peripheral circulation and can indicate whether the feet are indeed cold. Cold feet may suggest poor peripheral perfusion or circulation issues, which require further assessment.

B) Test feet for a positive Babinski reflex:
The Babinski reflex is typically tested to assess upper motor neuron dysfunction and is not directly relevant to evaluating the complaint of cold feet.

C) Measure skin elasticity around the ankles:
Measuring skin elasticity around the ankles may be relevant for assessing skin turgor and hydration status but is not specifically related to evaluating the client's complaint of cold feet.

D) Assess volume of the pedal pulses:
Assessing the volume of pedal pulses provides information about peripheral perfusion and circulation. Diminished or absent pedal pulses may indicate peripheral vascular disease or other circulatory issues contributing to cold feet. It's essential to evaluate the strength and symmetry of pedal pulses to determine peripheral vascular status.

E) Observe color of the feet and toes:
While observing the color of the feet and toes is important for assessing circulation and perfusion, it is not specific to evaluating the client's complaint of cold feet. However, color changes, such as pallor or cyanosis, may provide additional information about peripheral circulation and require further assessment.

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When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

Correct Answer is B

Explanation

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

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