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?
Cardiac atrophy.
Cardiac enlargement.
Benign variation.
Expected finding.
The Correct Answer is B
A. Cardiac atrophy would typically not present with an area of dullness upon percussion. Instead, you might expect a different set of findings related to the heart's size and function.
B. Cardiac enlargement is indicated by an area of dullness that extends beyond the normal borders of the heart. Dullness on percussion indicates the presence of solid or fluid-filled structures, such as an enlarged heart.
C. A benign variation in heart sounds or borders is usually within normal limits and does not typically show such pronounced changes in percussion notes.
D. This finding is not an expected normal finding. Normal heart borders are not usually marked by an area of dullness extending from the 5th to the 2nd intercostal space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Papules are small, raised, solid lesions, but they are not the typical primary skin lesion in an allergic reaction.
B. Wheals are raised, red, and itchy areas of the skin that appear in response to an allergic reaction, such as from an insect bite. Wheals are a hallmark sign of urticaria (hives) often seen in allergic reactions.
C. Fissuring refers to deep cracks or breaks in the skin, typically seen in conditions like chronic dermatitis or eczema, not in acute allergic reactions.
D. Excoriation involves skin damage caused by scratching and is secondary to itching, not a primary skin lesion of an allergic reaction.
Correct Answer is D
Explanation
A. Asking the client to follow a three-step task assesses complex functioning and executive skills, which is important but not the most immediate way to evaluate recent memory.
B. Repeating a series of unrelated numbers assesses short-term memory and attention span but does not specifically evaluate recent memory related to daily activities.
C. Asking about the year the client married his wife assesses long-term memory rather than recent memory. Long-term memory is often better preserved than recent memory in many cases of cognitive decline.
D. Asking the client to recall what he ate for breakfast assesses recent memory and is relevant to evaluating the type of memory loss described. Recent memory loss can impact the ability to remember recent events and activities.
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