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 ["C","D","E"]

Explanation

Answer: C. Age when the client started smoking.
Knowing when the client began smoking is essential for determining the total duration of smoking. This information allows the nurse to calculate how long the client has been exposed to tobacco, which is critical for assessing potential health risks associated with their smoking history.

D. Packs of cigarettes smoked per day.
This information is crucial as it directly contributes to the calculation of pack years. Understanding how many packs the client smokes each day helps quantify their level of tobacco exposure. For instance, smoking one pack per day for ten years results in ten pack years, while two packs per day over the same period would lead to twenty pack years.

E. Number of years the client smoked.
This detail is necessary to determine the total duration of the smoking habit. The total number of years smoked, combined with the daily pack consumption, provides a comprehensive view of the client's smoking history. It allows the nurse to assess the cumulative risk associated with long-term tobacco use, which is important for evaluating the client’s health and potential interventions.

Rationale for Options Not Selected:

A. Number of attempts to quit smoking.
While this information can provide insight into the client's motivation and efforts to quit, it is not relevant for calculating pack years. Pack years focus specifically on the amount and duration of smoking, rather than attempts to quit, which may be useful in assessing readiness for cessation interventions but does not factor into the calculation of exposure.

B. Client's current age.
Although the client's age can provide context regarding their smoking history, it is not necessary for the actual calculation of pack years. Instead, it is the age when the client started smoking, along with the total years smoked and the number of packs smoked per day, that are critical for this specific assessment. The current age is not needed to compute pack years directly.

Summary of Calculation:

To calculate pack years, use the formula:

Pack Years = (Number of packs smoked per day) × (Number of years smoked)

For example, if a client smoked 1 pack per day for 20 years, they would have 20 pack years. If they smoked 2 packs a day for the same period, that would equate to 40 pack years. This measurement is essential for understanding the health risks associated with smoking and guiding further assessment and intervention strategies.

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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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

While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

Summary of Calculation:

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 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?

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?

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The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?