Author Question: A nurse is auscultating different areas on an adult patient. Which technique should the nurse use ... (Read 28 times)

amal · **on:** Jul 22, 2018

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment?

a. Uses the bell to listen for lung sounds
b. Uses the diaphragm to listen for bruits
c. Uses the diaphragm to listen for bowel sounds
d. Uses the bell to listen for high-pitched murmurs

Question 2

While assessing the skin of an 82-year-old patient, a nurse discovers nonpainful, ruby red papules on the patient's trunk. What is the nurse's next action?

a. Explain that the patient has basal cell carcinoma and should watch for spread.
b. Document cherry angiomas as a normal older adult skin finding.
c. Tell the patient that this is a benign squamous cell carcinoma.
d. Record the presence of petechiae.

bob · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: C
The bell is best for hearing low-pitched sounds such as vascular (bruits) and certain heart sounds (low-pitched murmurs), and the diaphragm is best for listening to high-pitched sounds such as bowel and lung sounds and high-pitched murmurs.

Answer to Question 2

ANS: B
The skin is normally free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. Basal cell carcinoma is most common in sun-exposed areas and frequently occurs in a background of sun-damaged skin; it almost never spreads to other parts of the body. Squamous cell carcinoma is more serious than basal cell and develops on the outer layers of sun-exposed skin; these cells may travel to lymph nodes and throughout the body. Report abnormal lesions to the health care provider for further examination. Petechiae are nonblanching, pinpoint-size, red or purple spots on the skin caused by small hemorrhages in the skin layers.