The nurse knows to auscultate the tricuspid valve at which location?
Third left ICS
Second right ICS
Fourth left ICS
Second left ICS
The Correct Answer is C
A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.
B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.
C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.
D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.
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Correct Answer is B
Explanation
A) Eupnea: Eupnea refers to a normal respiratory rate, typically between 12 to 20 breaths per minute for adults. Given that the client’s respiratory rate is significantly lower than this range, documenting the finding as eupnea would not accurately reflect the client’s condition.
B) Bradypnea: Bradypnea is defined as a slower-than-normal respiratory rate, usually less than 12 breaths per minute. With the client's rate at 9 breaths per minute, this is an example of bradypnea. It is crucial for the nurse to document this finding accurately, even though the client denies feeling short of breath, as it could indicate an underlying issue requiring further assessment.
C) Tachypnea: Tachypnea indicates a faster-than-normal respiratory rate, typically over 20 breaths per minute. Since the client's respiratory rate is low at 9 breaths per minute, labeling it as tachypnea would be incorrect and misleading.
D) Dyspnea: Dyspnea refers to difficulty or discomfort in breathing. Although the client does not report feeling short of breath, it is essential to note that the low respiratory rate could still lead to respiratory distress, but it does not meet the criteria for dyspnea based on the client's self-report. Therefore, documenting this finding as dyspnea would not be appropriate.
Correct Answer is C
Explanation
A) Low self-esteem: While low self-esteem can develop as a result of limitations in physical abilities, it is not the most immediate concern in this scenario. Addressing the patient's functional capabilities and safety takes precedence.
B) His complaints of numbness in his hands: Numbness is a significant symptom of carpal tunnel syndrome, but the immediate priority is to ensure the patient can safely perform tasks. While it is important to address his symptoms, managing the risk associated with his condition is more critical.
C) Risk for injury: This is the most pressing concern for the patient. Given his difficulty holding tools, there is a heightened risk of accidents or injuries while working. Prioritizing safety measures is essential to prevent harm and ensure he can continue his work safely.
D) Persistent pain: While pain management is important, the focus should be on the immediate risk of injury related to the patient's inability to hold tools securely. Addressing safety concerns takes precedence over managing pain at this point.