The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

A 2-year-old who is demonstrating diaphragmatic breathing.

A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2.

A 75-year-old with a pneumothorax and a chest tube.

A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg).

Answer and Explanation

The Correct Answer is D

A) A 2-year-old who is demonstrating diaphragmatic breathing:
In young children, especially infants and toddlers, the PMI is typically easier to locate due to their smaller size and thinner chest wall. Diaphragmatic breathing, which is normal in infants and toddlers, does not necessarily interfere with locating the PMI.

B) A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2:
A BMI within the normal range does not necessarily affect the ability to locate the PMI. Additionally, physical fitness, such as being a long-distance runner, may contribute to better cardiovascular health and clearer identification of the PMI.

C) A 75-year-old with a pneumothorax and a chest tube:
In clients with a pneumothorax and a chest tube, the presence of medical devices and underlying respiratory conditions may affect the ability to locate the PMI. However, the primary challenge here would likely be due to the presence of the chest tube rather than the client's age alone.

D) A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg):
In individuals who are significantly overweight or obese, locating the PMI may be challenging due to increased chest wall thickness and adipose tissue. The increased depth of tissue can make palpating the PMI more difficult, leading to anticipated difficulty in locating it accurately.

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Correct Answer is C

Explanation

A) Ask about recent abdominal trauma:
While abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen. Additionally, without further evidence or symptoms suggestive of trauma, it may not be necessary to immediately inquire about recent abdominal trauma.

B) Observe the midline for scarring:
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions. However, the presence of a depressed umbilicus below the surface of the abdomen does not necessarily indicate scarring or previous surgery.

C) Document the normal finding:
A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.

D) Palpate the area for masses:
Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation. In the absence of other concerning findings, it may be unnecessary and potentially uncomfortable for the client to perform palpation based solely on the observation of a depressed umbilicus.

A. Abduct each hip while the client is supine. B. Flex the hip and knee while standing. C. Observe balance while the client stands. D. Inspect gluteal folds for symmetry.

Correct Answer is B

Explanation

A) Abduct each hip while the client is supine:
While assessing hip abduction can provide information about hip joint mobility, it may not be the most appropriate initial assessment for hip dysfunction. This action primarily evaluates the range of motion but may not specifically target dysfunction in the hip region.

B) Flex the hip and knee while standing:
Flexing the hip and knee while the client is standing can help assess hip function, particularly in weight-bearing positions. This action can reveal limitations in hip mobility and detect dysfunction such as pain or weakness during movement.

C) Observe balance while the client stands:
Observing balance while the client stands is important for assessing overall lower extremity function, including the hips. However, it may not specifically target dysfunction in the hip region and may provide more general information about mobility and stability.

D) Inspect gluteal folds for symmetry:
Inspecting gluteal folds for symmetry can help identify asymmetry or abnormalities in the hip region, but it may not provide direct information about hip dysfunction. This action is more focused on assessing external appearance rather than functional movement or mobility.

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The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

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Naxlex Comprehensive Predictor Exams

During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

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The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

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