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. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.
B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.
C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.
D. Background music may be distracting rather than helpful during the provision of important instructions.
Correct Answer is C
Explanation
Rationale:
A. The history of coronary artery bypass surgery is important but does not directly relate to the current symptoms.
B. A recent colonoscopy is not relevant to the client's current symptoms.
C. Long-term use of digoxin and furosemide is highly significant as these medications can lead to digoxin toxicity, especially in the context of dehydration or renal insufficiency. Symptoms like nausea, vomiting, and anorexia are classic signs of digoxin toxicity.
D. A history of depression is important but not immediately relevant to the current symptoms of nausea, vomiting, and anorexia.