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 A
Explanation
Rationale:
A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.
B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.
C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.
D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.
Correct Answer is A
Explanation
Rationale:
A.Allergic rhinitis is characterized by intranasal edema and swelling of the turbinates due to inflammation caused by allergens. This is a common physical finding in clients with allergic rhinitis.
B.Purulent secretions typically indicate an infection rather than an allergic condition.
C.Bilateral, pale gray nodules might suggest nasal polyps, which are associated with chronic sinusitis rather than acute allergic rhinitis.
D.Eye tearing is common in allergic rhinitis, but thick yellow nasal drainage suggests an infection rather than an allergic reaction.