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. S4 heart sound: An S4 heart sound is often associated with hypertensive heart disease or left ventricular hypertrophy, rather than congestive heart failure alone.
B. Harsh holosystolic murmur at the apex: This type of murmur is more indicative of mitral regurgitation rather than congestive heart failure.
C. S3 heart sound: An S3 heart sound is commonly associated with congestive heart failure, especially when there is volume overload and decreased left ventricular function.
D. Carotid bruits: Carotid bruits are associated with vascular issues rather than congestive heart failure.
Correct Answer is D
Explanation
A. It is easiest for the client to learn: While the ease of learning is important, the primary goal is effective detection of masses.
B. It takes the least amount of time: The time taken is less critical than the effectiveness of the technique in detecting abnormalities.
C. It causes the least amount of pain: Minimizing pain is not the main reason for choosing a particular technique; effectiveness in detecting masses is more critical.
D. It is the best technique to detect masses: The recommended pattern, often the vertical strip or circular pattern, is chosen because it is the most effective way to systematically cover the breast tissue and increase the likelihood of detecting abnormalities or masses.
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