When assessing the heart, the nurse inspects and palpitates which of the following?
Peritoneum and tricuspid area
Precordium and PMI
Precordium and apical heart rate
Peritoneum and left sternal border.
The Correct Answer is B
When assessing the heart, the nurse will inspect and palpate the precordium, which is the area of the chest overlying the heart, and the PMI (point of maximal impulse), which is the point on the chest where the heartbeat is the strongest. These assessments allow the nurse to gather information about the size, shape, and location of the heart and to detect any abnormalities in the heartbeat or rhythm. The peritoneum is a membrane lining the abdominal cavity and has no relevance in the assessment of the heart. The tricuspid area and left sternal border are areas of the chest that may be auscultated to assess heart sounds but are not palpated during a heart assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The sense of taste is primarily mediated by the facial nerve (cranial nerve VII) and the glossopharyngeal nerve (cranial nerve IX). However, testing the function of specific cranial nerves such as the hypoglossal nerve (cranial nerve XII) or cranial nerve XI (11) is not directly related to evaluating the patient's ability to taste. Therefore, options a, b, and c would not be the most appropriate actions for the nurse to take in this scenario.
Correct Answer is ["B","E"]
Explanation
A. Dilated pupils in response to dimmed lights are a normal response and not an indication of a
vision problem.
B. Pupils that remain dilated during an accommodation test indicate that the client may have an
issue with their autonomic nervous system and is not able to adjust their pupil size appropriately.
C. Far vision acuity of 20/20 bilaterally indicates normal vision.
D. A symmetrical pupillary light reflex response is a normal finding and not an indication of a vision
problem.
E. Frowning and squinting while reading the Snellen chart may indicate that the client is having difficulty seeing the letters clearly and may have a vision problem.
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