During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Record the findings as a normal response.

Determine if the client has a history of heart disease.

Obtain the client's blood pressure.

Compare the apical pulse force to the carotid pulse force.

Answer and Explanation

The Correct Answer is B

A.   If the apical impulse is more vigorous than expected, it may indicate an abnormal finding, such as hyperdynamic circulation or heart failure. The nurse should not simply record this without further investigation.
B.   It is important to investigate whether the client has a history of heart disease, as conditions like left ventricular hypertrophy, heart failure, or valvular heart disease could cause changes in the apical impulse. This provides context for understanding the findings.
C.   Obtaining the client’s blood pressure is important in assessing cardiovascular health, but the most immediate response to a more vigorous apical impulse would be to explore the potential cause, including heart disease, rather than simply measuring blood pressure.
D.   Comparing the apical pulse to the carotid pulse may help assess if the increased pulse force is generalized or localized, and whether it might be a sign of circulatory changes. This would help clarify whether the finding is normal or indicative of pathology.

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Correct Answer is B

Explanation

A. This statement could indicate exercise intolerance or shortness of breath with exertion, but it doesn't specifically relate to orthopnea. Orthopnea refers to difficulty breathing when lying flat, not with activity.
B. This statement is indicative of orthopnea. People with orthopnea often need to sleep with multiple pillows or sit up to relieve the shortness of breath they experience when lying flat, often due to heart failure or other respiratory conditions.
C. Nighttime coughing can be a symptom of various conditions, such as asthma or postnasal drip, but it is not specific to orthopnea. Orthopnea is more about difficulty breathing while lying down.
D. Wheezing is a sign of asthma or other respiratory conditions but does not directly correlate with orthopnea. Orthopnea is specifically about the inability to breathe comfortably when lying down, not about wheezing.

A. Tenting noted in subclavicular area. B. Loss of skin elasticity in the hand. C. Skin is warm and dry. D. Thinning hair in the lower extremities.

Correct Answer is A

Explanation

A. Tenting of the skin is a classic sign of dehydration. When the skin is pinched and does not return quickly to its normal position, it indicates a lack of fluid in the body. This is a common finding in dehydration, particularly in older adults.
B. Loss of skin elasticity is a natural part of the aging process and may not be directly related to dehydration. It is common in older adults and is not necessarily an indicator of fluid status.
C. Warm and dry skin can be a sign of dehydration, particularly if accompanied by other symptoms such as a dry mouth or increased heart rate. Dry skin occurs when there is insufficient moisture in the body, which is common in dehydration.
D. Thinning hair in the lower extremities is more often associated with circulation issues or aging. It is not a typical sign of dehydration and would not be used as a primary indicator for assessing hydration status.

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During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

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Naxlex Comprehensive Predictor Exams

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

Correct Answer is B

Explanation

When assessing an older adult client, which finding is most indicative of dehydration?

Correct Answer is A

Explanation

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