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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The bell of the stethoscope is best for detecting low-pitched sounds like murmurs or extra heart sounds.
B. A Doppler ultrasound is not necessary for routine auscultation of heart sounds.
C. Pulse oximetry does not provide relevant information about heart sounds.
D. Auscultating with the diaphragm is better for high-pitched sounds, so the bell is preferred for extra heart sounds.
Correct Answer is D
Explanation
A. A history of a fractured patella could potentially cause crepitation if there were long-term damage or improper healing. However, it is more likely that crepitation is related to degenerative changes, such as osteoarthritis.
B. Needle aspiration of the synovial space may have been performed to relieve fluid buildup or inflammation, but it would not directly explain the crepitation in the joint. Crepitation is more commonly seen in conditions that affect cartilage or joint surfaces.
C. Crepitation following knee arthroplasty is possible if there are complications, but it is more likely due to arthritis or degenerative joint disease if the patient has not undergone surgery. Arthroplasty would usually be associated with reduced crepitation.
D. Degenerative diseases, such as osteoarthritis, are the most likely cause of crepitation. As the cartilage wears away, the bone surfaces rub together, causing the characteristic crunching or grating sound when the joint is moved.
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