In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?
Left carotid pulse volume of 4+; right carotid pulse volume of 0.
Left carotid artery bruit present; no bruit heard in right carotid artery.
Left carotid artery has strong pulse; right carotid artery occluded.
Left carotid artery occlusion present; no occlusion of right carotid artery.
The Correct Answer is B
Rationale:
A. Pulse volume and bruit are different assessments; pulse volume is not graded in the context of auscultation findings.
B. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, often due to stenosis or narrowing. Documenting a "left carotid artery bruit present" accurately reflects the findings.
C. The presence of a bruit does not necessarily mean the pulse is strong or that there is occlusion.
D. A bruit indicates turbulent flow, not necessarily complete occlusion.
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Correct Answer is D
Explanation
Rationale:
A. Urinary output is important but not as critical as identifying the potential source of infection.
B. A 24-hour medication history is useful but secondary to identifying an acute infection.
C. The amount of serous drainage provides information on wound healing but does not confirm infection.
D. Increased confusion in an older adult, especially with a wound present, raises concern for infection, possibly sepsis. A WBC count can help identify infection and guide further treatment.
Correct Answer is A
Explanation
Rationale:
A. Dysphagia, or difficulty swallowing, significantly increases the risk of aspiration, especially when consuming a full liquid diet that may not be easily controlled in the mouth. Aspiration can lead to serious complications, such as aspiration pneumonia.
B. Oxygen administration via a face mask does not typically increase the risk of aspiration unless the client has underlying conditions affecting swallowing.
C. Sensory aphasia affects communication but does not directly impact the swallowing mechanism, so it poses less risk of aspiration compared to dysphagia.
D. While clients with a nasogastric tube may be at some risk for aspiration, the risk is lower compared to a client with dysphagia actively consuming liquids.