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 B

Explanation

A. Give the client 8 ounces (236.5 mL) of water to drink:
While encouraging hydration is important for overall urinary function, providing water to drink may not immediately address the client's current situation of difficulty providing a urine sample. It's essential to first determine if bladder distention is contributing to the client's symptoms.

B. Evaluate the client for bladder distention:
Given the client's symptoms of lower abdominal discomfort and difficulty providing a urine sample despite feeling the urge to urinate, bladder distention should be assessed. Bladder distention could indicate urinary retention, which may require intervention to relieve the discomfort and prevent complications such as urinary tract infection or bladder rupture.

C. Instruct the client to attempt to urinate again:
While encouraging the client to attempt to urinate again may be appropriate, it's essential to first assess for bladder distention to determine if there is an underlying issue contributing to the client's difficulty in providing a urine sample.

D. Send the sample for laboratory evaluation:
Sending the urine sample for laboratory evaluation is important for diagnostic purposes, but in this case, it's more important to address the immediate concern of the client's difficulty in providing an adequate sample. Evaluating for bladder distention would help guide further assessment and management.

A. Inspection of head and neck is observed in a straight alignment without lateral curves. B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. C. Observation of cervical range of motion reveals flexion and extension is 25 degrees. D. Palpation of the spinous processes and surrounding muscles are non-tender.

Correct Answer is C

Explanation

A) Inspection of head and neck is observed in a straight alignment without lateral curves:
This finding describes the normal alignment of the head and neck without lateral curves, indicating proper cervical spine alignment. While it provides information about cervical alignment, it does not directly suggest lifestyle habits that could contribute to neck stiffness and discomfort.

B) Evaluation of cranial nerve XI reveals flexion is maintained against full resistance:
Assessing cranial nerve XI (accessory nerve) involves testing the strength of the trapezius and sternocleidomastoid muscles. While weakness in these muscles may indicate pathology affecting the nerve, it does not specifically relate to lifestyle habits contributing to neck stiffness and discomfort.

C) Observation of cervical range of motion reveals flexion and extension is 25 degrees:
Limited cervical range of motion, such as the restricted flexion and extension described, may suggest musculoskeletal issues or lifestyle habits contributing to neck stiffness and discomfort. Further inquiry into the client's lifestyle habits, such as occupational activities, posture, and exercise habits, would be warranted to identify potential factors contributing to limited cervical range of motion.

D) Palpation of the spinous processes and surrounding muscles are non-tender:
Non-tender palpation of the spinous processes and surrounding muscles suggests the absence of acute musculoskeletal issues or inflammation in the cervical spine region. While it rules out tenderness on palpation, it does not provide specific information about lifestyle habits that could contribute to neck stiffness and discomfort.

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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)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is C

Explanation

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?