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 B

Explanation

A. Problem-oriented assessment: This focuses on specific issues or symptoms rather than evaluating outcomes of an established care plan.

B. Follow-up history: This type of assessment is conducted to evaluate the effectiveness of interventions and monitor progress towards outcomes identified in the care plan.

C. Comprehensive assessment: This involves a thorough evaluation of the client’s overall health status and history, not specifically focused on evaluating outcomes.

D. Emergency history: This is conducted in urgent situations to quickly assess and address immediate issues, not for evaluating outcomes of a care plan.

A. Secondary Prevention B. Primary Prevention C. Tertiary Prevention D. Educational Prevention

Correct Answer is B

Explanation

A. Secondary Prevention: This level focuses on early detection and treatment of diseases, such as screenings or exams, rather than promoting healthy behaviors.

B. Primary Prevention: This level involves strategies to prevent disease before it occurs, including promoting healthy lifestyles through exercise and nutrition.

C. Tertiary Prevention: This level aims to manage and improve quality of life for individuals with existing diseases to prevent complications, rather than preventing disease onset.

D. Educational Prevention: This term is not a standard classification in prevention levels; it refers to educational efforts but does not specifically align with the established levels of prevention.

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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

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