The nurse is assessing the apical pulse. Where should the stethoscope be placed?
Between the fourth and fifth intercostal space.
Between the third and fourth intercostal space.
Between the second and third intercostal space.
Between the first and second intercostal space.
The Correct Answer is A
Choice A rationale
The apical pulse is located at the fifth intercostal space at the left midclavicular line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Unfreezing is the first stage of Lewin’s Change Theory. It involves overcoming resistance to change and preparing for the upcoming change. In this case, the patient expressing interest in quitting smoking and asking about smoking cessation aids indicates that they are in the unfreezing stage.
Choice B rationale
Moving is the second stage of Lewin’s Change Theory. It involves taking the necessary steps towards change.
Choice C rationale
The term “Action” is not recognized as a stage in Lewin’s Change Theory.
Choice D rationale
Refreezing is the final stage of Lewin’s Change Theory. It involves establishing the change as a new habit, so it becomes the "norm"4.
Correct Answer is A
Explanation
Choice A rationale
Fatigue is a subjective symptom because it is experienced and reported by the patient. Patients with left-sided heart failure often experience fatigue due to the heart’s inability to pump sufficient blood to meet the body’s needs.
Choice B rationale
Elevated pulmonary capillary wedge pressure is an objective symptom that can be measured and observed by healthcare professionals. It is not something that a patient can directly experience or report.
Choice C rationale
Orthopnea, or difficulty breathing when lying flat, is a subjective symptom as it is based on the patient’s personal experience. However, it is not the best answer in this case because the question asks for the “subjective symptoms,” and fatigue is a more common subjective symptom of left-sided heart failure.
Choice D rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective symptom that can be observed by healthcare professionals. It is not something that a patient can directly experience or report.
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