When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Continue with the cardiac examination.

Dim the lights in the examination room.

Question the client about steroid use.

Position the client in high Fowler's position.

Answer and Explanation

The Correct Answer is D

A.   This may involve using a stethoscope to auscultate the apical pulse, as it might be more easily heard than felt, especially in individuals with significant muscle mass or other anatomical variations. This approach ensures that a thorough cardiac assessment is conducted.
B.   Dimming the lights would not impact the ability to palpate or auscultate the apical pulse. Lighting adjustments are generally more relevant for visual examinations rather than for palpation or auscultation of heart sounds. This action would not address the issue of locating the apical pulse.
C.   While steroid use can affect cardiovascular health, such as potentially causing changes in heart size or function, questioning the client about steroid use is not the immediate priority if the apical pulse cannot be palpated. The priority should be to ensure a correct assessment and use proper techniques to locate the pulse.
D.   Positioning the client in high Fowler's position (sitting up at a 60-90 degree angle) can help in various cardiac assessments and might make it easier to detect the apical pulse, especially if the client has a high muscle mass. This position can improve access to the chest and potentially facilitate better auscultation of heart sounds.

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Correct Answer is A

Explanation

A. A grade IV systolic murmur is considered loud and may be associated with a palpable thrill. In mitral valve regurgitation, the murmur is often best heard at the apex of the heart. A thrill, which is a vibration felt on the chest wall, is a sign of a more significant murmur. This description is consistent with a grade IV murmur, which is typically loud and may indeed be associated with a thrill.
B. Very loud, with no stethoscope, thrill easily palpable, heave visible.
B. A grade V systolic murmur is very loud and can be heard with the stethoscope barely touching the chest. It often comes with a palpable thrill and may be accompanied by a visible heave or lift of the

chest wall. This description is consistent with a grade V murmur, not grade IV. Therefore, it’s not the
correct description for a grade IV murmur.
C. A soft murmur, barely audible, describes a grade I or grade II systolic murmur. This does not match the characteristics of a grade IV murmur, which is louder and more easily heard. Therefore, this description does not support a grade IV murmur.
D. A moderately loud murmur, without a thrill, could describe a grade III murmur. Additionally, a "machine-like rumble" is more characteristic of a diastolic murmur, such as those heard in conditions like aortic regurgitation or mitral stenosis, rather than a systolic murmur associated with mitral valve regurgitation.

A. Ask the client to swallow while palpating along the sides of the trachea. B. Palpate deeply and firmly over the location of the thyroid gland. C. Document that thyroid gland size is normal with no visible goiter. D. Defer the thyroid exam and observe the client for signs of myxedema.

Correct Answer is A

Explanation

A. Asking the client to swallow while palpating along the sides of the trachea helps in assessing the thyroid gland's size and mobility. The thyroid gland is located just below the larynx, and during swallowing, it moves upward, which can make it easier to palpate and identify any enlargement or nodules.
B. Palpating deeply and firmly might not be necessary and could be uncomfortable for the client. Gentle palpation is usually adequate for assessing the thyroid gland. Excessive force is not recommended as it may not yield additional information and could cause discomfort.
C. If the thyroid gland is not visible, documenting that it is normal without further assessment may not be accurate. The gland could be enlarged (goiter) or have other abnormalities that are not apparent on visual inspection alone. Accurate documentation should include findings from palpation and other assessment techniques.
D. Deferring the thyroid exam and focusing on signs of myxedema is not ideal in this situation. Myxedema is a severe form of hypothyroidism that can have various signs, but the immediate need is to assess the thyroid gland directly for goiter or other abnormalities. It is essential to perform a thorough examination and not rely solely on observation of symptoms that might appear later.

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When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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