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 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.

A. Diverticulosis B. Nephrolithiasis C. Acute Cholecystitis D. Appendicitis

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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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

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