When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Continue with the cardiac examination.

Dim the lights in the examination room.

Question the client about steroid use.

Position the client in high Fowler's position.

Answer and Explanation

The Correct Answer is D

A.   This may involve using a stethoscope to auscultate the apical pulse, as it might be more easily heard than felt, especially in individuals with significant muscle mass or other anatomical variations. This approach ensures that a thorough cardiac assessment is conducted.
B.   Dimming the lights would not impact the ability to palpate or auscultate the apical pulse. Lighting adjustments are generally more relevant for visual examinations rather than for palpation or auscultation of heart sounds. This action would not address the issue of locating the apical pulse.
C.   While steroid use can affect cardiovascular health, such as potentially causing changes in heart size or function, questioning the client about steroid use is not the immediate priority if the apical pulse cannot be palpated. The priority should be to ensure a correct assessment and use proper techniques to locate the pulse.
D.   Positioning the client in high Fowler's position (sitting up at a 60-90 degree angle) can help in various cardiac assessments and might make it easier to detect the apical pulse, especially if the client has a high muscle mass. This position can improve access to the chest and potentially facilitate better auscultation of heart sounds.

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Correct Answer is D

Explanation

A. A painful ulcerated mucosal area inside the cheek that has been present for only 1 day is concerning but less alarming in the short term compared to chronic lesions. Acute ulcers can be caused by minor trauma, infections, or canker sores. While it is important to monitor and evaluate these lesions, especially if they persist or worsen, a duration of only 1 day typically suggests it might be related to a transient condition.
B. Stippled gingival margins that adhere firmly to the teeth can indicate gingival hyperplasia or certain systemic conditions like vitamin deficiencies. While this finding can be concerning and warrants further investigation into oral health or potential systemic issues, it is generally less urgent compared to other findings that may indicate malignancy or severe chronic conditions.

C. Small yellowish-white lesions on the buccal mucosa could be oral leukoplakia or aphthous ulcers, which can be benign or related to underlying conditions. While these lesions need to be assessed to determine their cause, they are usually less immediately concerning than persistent ulcers that could indicate more serious issues.
D. An ulceration under the tongue that has been present for three weeks is the most concerning finding. Chronic oral ulcers, especially those persisting for more than two weeks, can be indicative of serious conditions such as oral cancer or other malignancies. Persistent lesions warrant thorough investigation to rule out or address potential malignancy or other significant pathologies.

A. A 24 hour diet history. B. Status of current appetite. C. History of a recent weight loss. D. Condition of hair, nails, and skin.

Correct Answer is D

Explanation

A. While a 24-hour diet history can provide valuable information about a person's dietary intake, it may not accurately reflect their long-term nutritional habits. Additionally, some individuals may underreport or overreport their food intake.
B. A person's current appetite can be affected by various factors, including illness, medication, and emotional state. It may not be a reliable indicator of long-term nutritional status.
C. While weight loss can be a sign of nutritional problems, it is not always indicative of a deficiency. Other factors, such as increased physical activity or illness, can also contribute to weight loss.
D. The condition of hair, nails, and skin can provide valuable clues about a person's nutritional status.
For example, dry, brittle hair and nails, as well as pale or scaly skin, can be signs of nutrient deficiencies such as iron, vitamin B12, or protein deficiency. These visible signs can be more indicative of long-term nutritional deficiencies than other factors.

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When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

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