Which area would the nurse assess for a murmur due to aortic valve stenosis?

Right 5th intercostal space at the sternal border

Right 2nd intercostal space at the sternal border

Left 5th intercostal space at the mid-clavicular line

Left 2nd intercostal space at the mid-clavicular line

Answer and Explanation

The Correct Answer is B

Choice A reason: The right 5th intercostal space at the sternal border is near the tricuspid valve, where murmurs from tricuspid regurgitation or stenosis are typically heard. Aortic valve stenosis murmurs, caused by turbulent flow through a narrowed aortic valve, are not prominent here, making this an incorrect assessment site.

Choice B reason: The right 2nd intercostal space at the sternal border is the aortic area, ideal for auscultating aortic valve stenosis murmurs. These murmurs are harsh, crescendo-decrescendo, and systolic, radiating to the carotid arteries due to turbulent blood flow through the stenosed aortic valve, making this the correct site.

Choice C reason: The left 5th intercostal space at the mid-clavicular line is the mitral valve area, where mitral regurgitation or stenosis murmurs are heard. Aortic valve stenosis murmurs originate from the aortic root and are not best detected here, rendering this choice incorrect.

Choice D reason: The left 2nd intercostal space at the mid-clavicular line is near the pulmonic valve, where pulmonic stenosis murmurs are auscultated. Aortic valve stenosis murmurs are not prominent in this area, as they are specific to the aortic region, making this an incorrect choice.

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Correct Answer is B

Explanation

Choice A reason: Reading handheld print tests reading near vision, not standard visual acuity, which requires distance assessment. The Snellen chart at 20 feet is the standard, so this is incorrect for acuity testing.

Choice B reason: The Snellen chart, positioned 20 feet away, is the standard method for assessing visual acuity in adolescents, providing a reliable measure of distance vision. This is the correct procedure for the nurse.

Choice C reason: The confrontation test assesses peripheral vision, not central acuity. The Snellen chart measures sharpness of vision, so this is incorrect for the purpose of visual acuity assessment.

Choice D reason: Reading newsprint at 12–14 inches tests near vision, not distance acuity, which is the standard for screening. The Snellen chart at 20 feet is appropriate, so this is incorrect.

A. Large and fixed to the tissue B. Large and non-mobile C. Granular texture D. Not palpable

Correct Answer is D

Explanation

Choice A reason: Large, fixed lymph nodes suggest pathology, such as malignancy or chronic infection, as they indicate adherence to surrounding tissues. In healthy adults, lymph nodes are typically small and not fixed, making this an abnormal and incorrect characteristic.

Choice B reason: Large, non-mobile lymph nodes may indicate infection or malignancy, as healthy nodes are usually small and mobile. Non-mobility suggests tissue infiltration, which is pathological, making this an incorrect description of normal lymph node characteristics.

Choice C reason: Granular texture is not a standard term for describing lymph nodes. Healthy nodes, when palpable, feel smooth and soft. Granular suggests abnormality, possibly infection or malignancy, making this an inaccurate characteristic for healthy lymph nodes.

Choice D reason: In healthy adults, lymph nodes are typically not palpable, as they are small, soft, and non-tender, blending into surrounding tissues. Palpable nodes often indicate inflammation or pathology, making this the correct description of a normal finding.

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Which area would the nurse assess for a murmur due to aortic valve stenosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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