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Hesi RN Health Assessment Proctored Exam
Total Questions : 57
Showing 10 questions, Sign in for moreThe client is a 65-year-old female who comes to the emergency department (ED) via personal vehicle with husband in attendance. The client has a history of hypertension (HTN) and peripheral edema.
The nurse completes a cardiovascular assessment. The nurse is assessing the point of maximal impulse (PMI). After locating the angle of Louis, the nurse finds the second intercostal space. The nurse slides the fingers down the left side of the sternum to the fifth intercostal space, then over to the left midclavicular line.
Patient Data
The nurse reviews landmarks for assessing the apical pulse at the point of maximal impulse (PMI).
Click to highlight the landmarks that are used to find the PMI to auscultate the apical pulse.
The nurse completes a cardiovascular assessment. The nurse is assessing the point of maximal impulse (PMI). After locating the angle of Louis, the nurse finds the second intercostal space. The nurse slides the fingers down the left side of the sternum to the fifth intercostal space, then over to the left midclavicular line.
Explanation
This question focuses on identifying anatomical landmarks used to locate the point of maximal impulse (PMI) for auscultation of the apical pulse. The PMI represents the location where the left ventricle’s impulse is most strongly felt against the chest wall during cardiac contraction. Accurate identification of this point is essential in cardiovascular assessment because it reflects left ventricular function and cardiac size. Nurses use consistent surface landmarks to ensure correct placement of the stethoscope for apical pulse assessment.
Rationale:
• Second intercostal space: The nurse first uses the angle of Louis (sternal angle) to identify the second intercostal space as an initial landmark for orientation. This provides a reliable reference point for counting intercostal spaces downward along the sternum. Although the PMI is not located here, it is an essential starting point for accurate anatomical mapping. It ensures consistent identification of cardiac landmarks during assessment.
• Left sternal border down to the fifth intercostal space: From the second intercostal space, the nurse moves inferiorly along the left sternal border to locate the fifth intercostal space. This step helps trace the vertical alignment of the heart along the sternum. It is part of the systematic approach used to locate the PMI. This method ensures accuracy before moving laterally to identify the apical impulse.
• Left midclavicular line at the fifth intercostal space: The point of maximal impulse is typically located at the fifth intercostal space along the left midclavicular line. This is where the apical pulse is best auscultated in adults with normal cardiac positioning. The PMI reflects the apex of the left ventricle as it contacts the chest wall during systole. Identifying this landmark is critical for assessing heart rate, rhythm, and potential cardiac enlargement.
During the admission assessment of an older adult female, the nurse notes the presence of kyphosis. The client tells the nurse that she has a history of osteoporosis. To obtain additional information related to this finding, the nurse should question the client about which additional information in her history?
Which assessment finding requires the most immediate follow-up by the nurse?
When assessing a client's skin, which finding should the nurse report to the healthcare provider (HCP)?
In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?
A client arrives to the clinic and describes seeing occasional tiny floating spots in vision that moves when trying to focus on them. The client denies eye pain, flashes of light, recent trauma or inflammation to the eye, and has no history of laser or eye surgery. The client informs that glasses are used only for reading and close work. Based on these findings, which action should the nurse take?
A client arrives at the clinic and describes having rectal pressure, burning, and itching around the anus. During the health assessment, which technique should the nurse implement to determine if the client has hemorrhoids?
An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect this client's sleep?
The nurse is interviewing a male client who is admitted for chest pain. With each question, the client answers in broken English that is mixed with French phrases and looks to his wife. Frequently his wife anxiously speaks up and contradicts each of the client's responses. Which action should the nurse take?
The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this older adult client?
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