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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Subjective: Subjective data refers to information reported by the patient directly, which is not applicable in this case since the client cannot communicate.
B. Tertiary: This term is not commonly used in the context of data sources in health assessments.
C. Secondary: Secondary data is information provided by someone other than the patient, such as a family member or caregiver, which is applicable here since the daughter is providing the information.
D. Primary: Primary data is directly obtained from the patient, not from a secondary source like the daughter.
Correct Answer is C
Explanation
A. Diverticulosis: This condition involves the formation of pouches in the colon and is not associated with Murphy's sign.
B. Nephrolithiasis: This refers to kidney stones and is not associated with Murphy's sign.
C. Acute Cholecystitis: Murphy's sign is a clinical test for acute cholecystitis, which is inflammation of the gallbladder. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.
D. Appendicitis: Appendicitis is an inflammation of the appendix and is not related to Murphy's sign.
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