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. "When was the last time you experienced a fever?": This question pertains to the assessment of body temperature, which is part of the vital signs but not the "fifth vital sign."

B. "Do you consider yourself a happy person?": This question focuses on emotional well-being, not the "fifth vital sign."

C. "Do you monitor your blood pressure regularly?": This pertains to blood pressure monitoring, which is one of the vital signs but not the "fifth vital sign."

D. "Are you experiencing any pain right now?": Pain is often referred to as the "fifth vital sign" and is assessed to understand a patient's overall health and comfort.

A. Subjective B. Tertiary C. Secondary D. Primary

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.

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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

Which general survey question focuses on the common "fifth vital sign"?

Correct Answer is D

Explanation

The nurse is assessing an older adult client at a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

Correct Answer is C

Explanation

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