When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

Auscultate for any cardiac murmurs

Compare the apical and radial pulse rates

Palpate the quality of the peripheral pulses

Find the point of maximal impulse

Check capillary refill time

Answer and Explanation

The Correct Answer is A

A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.

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Correct Answer is C

Explanation

A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.

A. venous insufficiency B. claudication C. muscle cramps D. deep vein thrombosis E. bruit from turbulent blood flow

Correct Answer is B

Explanation

A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.

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When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

Correct Answer is C

Explanation

A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

Correct Answer is B

Explanation

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