A nurse reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

The atria contract toward the end of diastole and push the remaining blood into the ventricles

Contraction the atria at the beginning of diastole can be felt as a click

The ventricles contract during systole and attempt to push against closed atria

Atrial kick is the pressure exerted against the atria as the ventricles contract during systole

Answer and Explanation

The Correct Answer is A

A) The atria contract toward the end of diastole and push the remaining blood into the ventricles:
This is the correct definition of the atrial kick. The atrial kick refers to the contraction of the atria just before the ventricles contract, which occurs late in diastole. During this phase, the atria contract to push the remaining blood into the ventricles, ensuring that the ventricles are as filled as possible before the next ventricular contraction. This action contributes to about 20–30% of the ventricular filling, especially important in situations where the heart rate is fast, as there may be less time for passive filling during diastole.

B) Contraction of the atria at the beginning of diastole can be felt as a click:
This statement is incorrect. Atria contract at the end of diastole, not the beginning. The atrial contraction is not typically felt as a "click." If there is a "click" sound, it could indicate an abnormal heart valve sound, such as from a mitral valve prolapse, rather than the normal atrial contraction. The atrial kick itself is not associated with any audible click but may be heard as part of the S4 heart sound, especially in conditions with stiff ventricles (such as hypertension or heart failure).

C) The ventricles contract during systole and attempt to push against closed atria:
This is not an accurate description of the atrial kick. During systole, the ventricles contract and push blood into the aorta and pulmonary artery through the open semilunar valves, not against the atria. The atrial kick is a part of diastole, not systole, and involves the atria pushing blood into the ventricles, not the ventricles pushing against the atria.

D) Atrial kick is the pressure exerted against the atria as the ventricles contract during systole:
This description is incorrect. The atrial kick occurs when the atria contract near the end of diastole, not during systole. During systole, the ventricles contract and pump blood out of the heart, but this is not related to the atrial kick. Instead, the atrial kick is the contribution of atrial contraction to the final phase of ventricular filling, just before the ventricles contract.

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Correct Answer is B

Explanation

A) Inspection of the shape and configuration of the chest wall during normal breathing:
While inspection is an important part of the initial assessment, it is not the most effective method to confirm symmetric expansion of the chest. Inspecting the shape and configuration of the chest can reveal abnormalities, such as a barrel chest or scoliosis, but it does not directly assess the movement of the chest wall during breathing. The most reliable technique to assess for symmetric chest expansion involves palpation, not just visual inspection.

B) Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10:
This is the best technique for assessing symmetric chest expansion. The nurse places their hands with the thumbs pointing toward each other at the level of the T9 or T10 vertebrae on the patient's posterior chest wall. As the client inhales deeply, the nurse observes whether both thumbs move symmetrically outward. This test directly evaluates the expansion of the lungs and chest wall during respiration, making it the most accurate method for assessing symmetric chest movement.

C) Percussion of the posterior chest to initiate vibration of the lung structures:
Percussion is used to assess the underlying lung tissue and detect abnormalities such as fluid or air in the lungs (e.g., pneumonia, pleural effusion, or pneumothorax), but it does not assess chest expansion. Percussion helps in evaluating lung resonance but is not a direct method to confirm whether both sides of the chest are expanding symmetrically during breathing. It is a diagnostic technique, not an assessment for expansion symmetry.

D) Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine":
This technique assesses for tactile fremitus, which involves feeling for vibrations as the client speaks. While it is useful in evaluating lung consolidation (such as pneumonia), it does not directly assess the symmetry of chest expansion. Tactile fremitus helps detect areas of increased or decreased vibration due to fluid or tissue changes in the lungs but does not measure how equally the chest is expanding during inhalation.

A. Obtain a threat culture for possible streptococcal (strep) infection B. Continue with the assessment, looking for any other abnormal findings C. Refer the client to their primary provider D. No response is needed, this appearance is normal for the tonsils

Correct Answer is D

Explanation

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture for streptococcal infection is generally warranted when there are signs and symptoms of a bacterial infection, such as a sore throat, fever, exudate on the tonsils, or swollen lymph nodes. The description provided—involuted, granular tonsils with deep crypts—is a normal, age-related finding and not indicative of an infection. Therefore, obtaining a throat culture is unnecessary unless additional clinical signs of infection are present.

B) Continue with the assessment, looking for any other abnormal findings:
While it is always important to complete a thorough assessment and look for other abnormal findings, the specific characteristics described (involuted, granular tonsils with deep crypts) are normal, particularly in adults. This is a common finding and does not require further investigation unless accompanied by other symptoms such as pain, swelling, or visible pus, which would warrant a closer look.

C) Refer the client to their primary provider:
Referral to a primary provider is generally recommended if there are significant concerns about the tonsils, such as persistent swelling, pain, or signs of infection. However, the description provided does not suggest a pathological issue; these characteristics are typically considered normal in adults. Referral would only be necessary if additional concerning symptoms were present, such as fever, difficulty swallowing, or changes in voice.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Involuted (shrunken), granular tonsils with deep crypts are a normal, age-related finding, especially in adults. Over time, the tonsils tend to shrink and develop more pronounced crypts (pockets). This is part of the natural aging process and is not usually a sign of pathology. These tonsil changes are often seen in individuals who have had repeated infections or as part of the natural aging process.

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A nurse reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?

Correct Answer is B

Explanation

A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. The nurse should recognize that which of the following is the correct response to these findings?

Correct Answer is D

Explanation

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A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?

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