When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?
Clavicle.
Lung apex.
Aortic site.
Sternum.
The Correct Answer is B
Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.
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Correct Answer is D
Explanation
Choice A rationale
Demonstrating signs of early dementia involves more than just walking aimlessly and staring blankly. It includes memory loss, difficulty with complex tasks, and changes in personality or behavior.
Choice B rationale
Appearing confused and depressed is a subjective interpretation and does not accurately describe the observed behavior. Documentation should be objective and specific.
Choice C rationale
Ambulatory and disoriented to place is a partial description but does not capture the full extent of the observed behavior, including the blank expression.
Choice D rationale
Wandering behavior with flat affect accurately describes the observed behavior. It is specific and objective, noting both the physical action (wandering) and the emotional state (flat affect).
Correct Answer is B
Explanation
Choice A rationale
The description of pulse volume (4+ and 0) is not appropriate for documenting a bruit. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, not pulse volume.
Choice B rationale
A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis. The presence of a bruit in the left carotid artery and the absence of sound in the right carotid artery should be documented as such.
Choice C rationale
While a bruit can indicate partial occlusion of an artery, it does not confirm complete occlusion. Complete occlusion would typically result in the absence of blood flow and no sound. Therefore, this choice is incorrect.
Choice D rationale
The presence of a bruit does not necessarily indicate a strong pulse. It indicates turbulent blood flow, which is often due to narrowing or partial blockage of the artery. This choice is incorrect