The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Use tangential lighting.

Assist the client to a standing position.

Use perpendicular lighting.

Focus a penlight on the client's chest.

Answer and Explanation

The Correct Answer is C

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Focused: A focused assessment targets specific concerns or symptoms rather than including a complete health history and physical examination.

B. Comprehensive: A comprehensive assessment includes both a detailed health history and a thorough physical assessment, providing a complete picture of the patient’s health.

C. Ongoing: Ongoing assessments are periodic evaluations to monitor changes or progress in a patient’s condition, not necessarily encompassing a full health history and physical examination.

D. Emergency: Emergency assessments are conducted quickly to address immediate life-threatening issues, not to gather a full health history or perform a comprehensive physical exam.

A. Mental status examination B. Mouth and throat C. Head and face D. Ears E. Hematocrit 47% (37% to 47%)

Correct Answer is D

Explanation

A. Mental status examination: This part of the assessment evaluates cognitive functions, not sensory functions related to cranial nerve VIII.

B. Mouth and throat: This area assesses cranial nerves related to swallowing and speech but not the sensory function of cranial nerve VIII.

C. Head and face: This includes assessing cranial nerves related to facial sensation and movement but not the auditory function of cranial nerve VIII.

D. Ears: Cranial nerve VIII, the vestibulocochlear nerve, is responsible for hearing and balance, so assessing sensory function related to this nerve occurs during the examination of the ears.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which type of assessment includes a health history and physical assessment?

Correct Answer is B

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

Correct Answer is D

Explanation

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

While inspecting the external eye of a client, the nurse notes that the client's right eyelid droops. Which term would the nurse use to document this finding?