The best position for the nurse to position the client in order ...

[Jipu 123]

The best position for the nurse to position the client in order to auscultate the apical site, if a low-pitched murmur is suspected during prior assessment, is:
 
  1. Sitting up
  2. Standing
  3. Lying on the left side
  4. Dorsal recumbent

Question 2

Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should:
 
  1. Ask the client to read printed material
  2. Assess the directions of gaze
  3. Assess the client's ability to hear the spoken word
  4. Ask the client to say ah

[aprice35067]

Answer to Question 1

ANS: 3
Extra heart sounds or heart murmurs are heard more easily with the client lying on the left side (lateral recumbent) with the stethoscope at the apical site. Sitting upright is used for assessing lung expansion and symmetry of the upper extremities. Standing is not the best position for aus-cultating a heart murmur. The dorsal recumbent position is best used for abdominal assessment.

Answer to Question 2

ANS: 3
To test cranial nerve VIII (auditory), the nurse should assess the client's ability to hear the spo-ken word. To test cranial nerve II (optic), the nurse should assess the client's ability to read printed material. To test cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), the nurse should assess the client's directions of gaze. To assess cranial nerve X (vagus), the nurse should ask the client to say ah.

[Jipu 123]

Excellent

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Gracias!