While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Expected finding.

Cardiac enlargement.

Benign variation.

Cardiac atrophy.

None

Answer and Explanation

The Correct Answer is B

B. Cardiac enlargement:
This is the most likely interpretation of the findings. A significant area of dullness across a larger portion of the chest, as described, suggests that the heart is enlarged (cardiomegaly). Enlargement of the heart may result from various conditions, such as heart failure, hypertension, or valvular disease, leading to increased cardiac size and the shift in the percussion borders. This could indicate that the heart has expanded beyond its normal anatomical limits, and further assessment, such as imaging, would be necessary to confirm the diagnosis.

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Correct Answer is B

Explanation

Answer: B. Opening a bar soap package.

Rationale:

A) Telephoning a family member:
Using a telephone is considered an instrumental activity of daily living (IADL), which involves more complex tasks required for independent living, such as managing communication. While important, it does not directly assess the physical and motor skills required for basic self-care.

B) Opening a bar soap package:
Opening a bar soap package involves fine motor skills and hand coordination, which are necessary for performing basic activities of daily living (ADLs). ADLs refer to essential self-care tasks like bathing, dressing, and grooming. Being able to open soap indicates the client has the dexterity needed for personal hygiene.

C) Sorting a collection of socks:
Sorting socks is more cognitive than motor-oriented, and it assesses organization skills, which are more aligned with IADLs rather than ADLs. It does not specifically evaluate the client’s ability to perform tasks related to basic self-care.

D) Reading a short paragraph:
Reading a paragraph evaluates literacy or cognitive function but is not directly related to performing ADLs. ADLs focus on physical activities necessary for daily living, such as dressing, eating, or bathing.

A. Inspection of head and neck is observed in a straight alignment without lateral curves. B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. C. Observation of cervical range of motion reveals flexion and extension is 25 degrees. D. Palpation of the spinous processes and surrounding muscles are non-tender.

Correct Answer is C

Explanation

A) Inspection of head and neck is observed in a straight alignment without lateral curves:
This finding describes the normal alignment of the head and neck without lateral curves, indicating proper cervical spine alignment. While it provides information about cervical alignment, it does not directly suggest lifestyle habits that could contribute to neck stiffness and discomfort.

B) Evaluation of cranial nerve XI reveals flexion is maintained against full resistance:
Assessing cranial nerve XI (accessory nerve) involves testing the strength of the trapezius and sternocleidomastoid muscles. While weakness in these muscles may indicate pathology affecting the nerve, it does not specifically relate to lifestyle habits contributing to neck stiffness and discomfort.

C) Observation of cervical range of motion reveals flexion and extension is 25 degrees:
Limited cervical range of motion, such as the restricted flexion and extension described, may suggest musculoskeletal issues or lifestyle habits contributing to neck stiffness and discomfort. Further inquiry into the client's lifestyle habits, such as occupational activities, posture, and exercise habits, would be warranted to identify potential factors contributing to limited cervical range of motion.

D) Palpation of the spinous processes and surrounding muscles are non-tender:
Non-tender palpation of the spinous processes and surrounding muscles suggests the absence of acute musculoskeletal issues or inflammation in the cervical spine region. While it rules out tenderness on palpation, it does not provide specific information about lifestyle habits that could contribute to neck stiffness and discomfort.

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While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

Correct Answer is B

Explanation

Rationale:

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is C

Explanation

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

When evaluating a client's rectal bleeding, which findings should the nurse document?

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?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

To assess a client's pupillary reaction to accommodation, 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?