The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

A 2-year-old who is demonstrating diaphragmatic breathing.

A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2.

A 75-year-old with a pneumothorax and a chest tube.

A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg).

Answer and Explanation

The Correct Answer is D

A) A 2-year-old who is demonstrating diaphragmatic breathing:
In young children, especially infants and toddlers, the PMI is typically easier to locate due to their smaller size and thinner chest wall. Diaphragmatic breathing, which is normal in infants and toddlers, does not necessarily interfere with locating the PMI.

B) A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2:
A BMI within the normal range does not necessarily affect the ability to locate the PMI. Additionally, physical fitness, such as being a long-distance runner, may contribute to better cardiovascular health and clearer identification of the PMI.

C) A 75-year-old with a pneumothorax and a chest tube:
In clients with a pneumothorax and a chest tube, the presence of medical devices and underlying respiratory conditions may affect the ability to locate the PMI. However, the primary challenge here would likely be due to the presence of the chest tube rather than the client's age alone.

D) A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg):
In individuals who are significantly overweight or obese, locating the PMI may be challenging due to increased chest wall thickness and adipose tissue. The increased depth of tissue can make palpating the PMI more difficult, leading to anticipated difficulty in locating it accurately.

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Correct Answer is B

Explanation

A) Retracted and non-mobile tympanic membrane: This finding is typically associated with conditions such as eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described in this scenario.

B) Red, edematous ear canal with no visualization of the tympanic membrane: This description aligns with otitis externa, commonly known as "swimmer's ear." The client's history of recent swimming, itching, pain, and discharge with a musty odor are classic signs of this condition. In otitis externa, the ear canal often appears red and swollen, and the inflammation can obstruct the view of the tympanic membrane.

C) Translucent, pearly gray and mobile tympanic membrane: This appearance indicates a normal, healthy ear and is inconsistent with the symptoms of pain, itching, and discharge described by the client.

D) Thickened and bulging tympanic membrane: This finding is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum, causing it to bulge. However, it does not match the scenario of external ear canal inflammation and discharge following swimming.

A. Ask the client if he knows the year he married his wife. B. Determine if client can recall what he ate for breakfast. C. Instruct the client to follow a three-step task. D. Tell the client to repeat a series of unrelated numbers.

Correct Answer is B

Explanation

A) Ask the client if he knows the year he married his wife:
While this question may assess long-term memory, it relies on specific episodic memory of a past event. Assessing recent memory loss typically involves evaluating the ability to recall recent events or information.

B) Determine if the client can recall what he ate for breakfast:
Assessing the client's ability to recall recent events, such as what he ate for breakfast, can provide valuable information about recent memory function. This assessment is relevant to the family's concerns about recent memory loss.

C) Instruct the client to follow a three-step task:
Assessing the client's ability to follow a three-step task evaluates executive function and working memory but may not directly assess recent memory loss, which is the family's concern.

D) Tell the client to repeat a series of unrelated numbers:
Assessing the client's ability to repeat a series of unrelated numbers tests short-term memory but does not specifically address recent memory loss or the family's concerns about it.

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The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

Correct Answer is B

Explanation

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

Correct Answer is B

Explanation

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?