During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Record the findings as a normal response.

Determine if the client has a history of heart disease.

Obtain the client's blood pressure.

Compare the apical pulse force to the carotid pulse force.

Answer and Explanation

The Correct Answer is B

A.   If the apical impulse is more vigorous than expected, it may indicate an abnormal finding, such as hyperdynamic circulation or heart failure. The nurse should not simply record this without further investigation.
B.   It is important to investigate whether the client has a history of heart disease, as conditions like left ventricular hypertrophy, heart failure, or valvular heart disease could cause changes in the apical impulse. This provides context for understanding the findings.
C.   Obtaining the client’s blood pressure is important in assessing cardiovascular health, but the most immediate response to a more vigorous apical impulse would be to explore the potential cause, including heart disease, rather than simply measuring blood pressure.
D.   Comparing the apical pulse to the carotid pulse may help assess if the increased pulse force is generalized or localized, and whether it might be a sign of circulatory changes. This would help clarify whether the finding is normal or indicative of pathology.

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Correct Answer is D

Explanation

A. This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B. This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C. Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D. This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

A. Morning stiffness quickly resolves B. Small joints of the hand C. Fatigue and fever D. Joint swelling E. Heberden nodes F. Symmetrical involvement G. Pain increases with motion

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Morning stiffness quickly resolves:

Rheumatoid Arthritis: Morning stiffness is a hallmark of rheumatoid arthritis, although it typically lasts more than just a brief period.

Small joints of the hand:

Rheumatoid Arthritis: Rheumatoid arthritis commonly affects the small joints of the hands and wrists, leading to pain, stiffness, and swelling.

Fatigue and fever:

Rheumatoid Arthritis: Systemic symptoms like fatigue and low-grade fever are often associated with rheumatoid arthritis due to its inflammatory nature.

Joint swelling:

Rheumatoid Arthritis: Swelling of the joints is a key symptom of rheumatoid arthritis, typically due to inflammation and fluid accumulation within the joint.

Heberden nodes:

Not Applicable: Heberden nodes are associated with osteoarthritis, not rheumatoid arthritis. These nodes occur at the distal interphalangeal joints.

Symmetrical involvement:

Rheumatoid Arthritis: One of the classic features of rheumatoid arthritis is symmetrical involvement of joints, particularly in the hands and wrists.

Pain increases with motion:

Rheumatoid Arthritis: Joint pain that increases with motion is a common symptom of rheumatoid arthritis, reflecting active inflammation in the joints.

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During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

Correct Answer is D

Explanation

Patient Data Exhibits Nurse analyzes the assessment findings. Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

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