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 A

Explanation

A. Skin tenting is a sign of dehydration. It occurs when the skin, after being pinched, does not quickly return to its normal position. This is often seen in areas with loose skin such as the subclavicular region.
B. Loss of skin elasticity is a normal aging process and not specifically indicative of dehydration. It can be seen in older adults regardless of hydration status.
C. Warm and dry skin can be a sign of dehydration. Dehydration leads to reduced sweating, which can result in dry skin, and it may also increase the body temperature, making the skin feel warm.
D. Thinning hair, especially in the lower extremities, is typically associated with circulatory issues or aging. It is not a direct sign of dehydration.

A. Anal mucosa prolapse and loose sphincter tone. B. Dried dark red blood on swollen external hemorrhoids. C. Serosanguineous and purulent exudate from anus. D. Tears of the anal mucosa with old blood around anus.

Correct Answer is B

Explanation

A. Anal mucosa prolapse may be a concern but would not explain the appearance of the dark red blood and external hemorrhoidal mass.
B. Dried, dark red blood on swollen external hemorrhoids suggests hemorrhoidal bleeding, which is common and associated with the appearance of a purple, shiny tissue mass.
C. Serosanguineous or purulent exudate suggests infection or other concerns but does not fit the description of the observed finding in this case.
D. Tears in the anal mucosa with old blood may occur, but they are not as likely to present as a shiny, purple mass with dark red blood on the surface.

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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?

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Naxlex Comprehensive Predictor Exams

When assessing an older adult client, which finding is most indicative of dehydration?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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