The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Use tangential lighting.

Assist the client to a standing position.

Use perpendicular lighting.

Focus a penlight on the client's chest.

Answer and Explanation

The Correct Answer is C

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

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Correct Answer is D

Explanation

A. Mental status examination: This part of the assessment evaluates cognitive functions, not sensory functions related to cranial nerve VIII.

B. Mouth and throat: This area assesses cranial nerves related to swallowing and speech but not the sensory function of cranial nerve VIII.

C. Head and face: This includes assessing cranial nerves related to facial sensation and movement but not the auditory function of cranial nerve VIII.

D. Ears: Cranial nerve VIII, the vestibulocochlear nerve, is responsible for hearing and balance, so assessing sensory function related to this nerve occurs during the examination of the ears.

A. It filters harmful substances from the body. B. It drains capillary blood from the circulation. C. It produces protective antibodies. D. It manufactures T lymphocytes.

Correct Answer is A

Explanation

A. It filters harmful substances from the body: The lymphatic system plays a crucial role in filtering lymph fluid and removing harmful substances, such as pathogens and toxins, through lymph nodes.

B. It drains capillary blood from the circulation: The lymphatic system does not directly drain capillary blood; instead, it collects interstitial fluid and returns it to the bloodstream.

C. It produces protective antibodies: Antibodies are produced by B lymphocytes in the immune system, not directly by the lymphatic system itself.

D. It manufactures T lymphocytes: While the lymphatic system is involved in the maturation and function of T lymphocytes, their manufacture occurs in the bone marrow and thymus rather than the lymphatic system itself.

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The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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