While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Expected finding.

Cardiac enlargement.

Benign variation.

Cardiac atrophy.

None

Answer and Explanation

The Correct Answer is B

B. Cardiac enlargement:
This is the most likely interpretation of the findings. A significant area of dullness across a larger portion of the chest, as described, suggests that the heart is enlarged (cardiomegaly). Enlargement of the heart may result from various conditions, such as heart failure, hypertension, or valvular disease, leading to increased cardiac size and the shift in the percussion borders. This could indicate that the heart has expanded beyond its normal anatomical limits, and further assessment, such as imaging, would be necessary to confirm the diagnosis.

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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. Retracted and non-mobile tympanic membrane. B. Red, edematous ear canal with no visualization of the tympanic membrane. C. Translucent, pearly gray and mobile tympanic membrane. D. Thickened and bulging tympanic membrane.

Correct Answer is B

Explanation

A) Retracted and non-mobile tympanic membrane: This finding is typically associated with conditions such as eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described in this scenario.

B) Red, edematous ear canal with no visualization of the tympanic membrane: This description aligns with otitis externa, commonly known as "swimmer's ear." The client's history of recent swimming, itching, pain, and discharge with a musty odor are classic signs of this condition. In otitis externa, the ear canal often appears red and swollen, and the inflammation can obstruct the view of the tympanic membrane.

C) Translucent, pearly gray and mobile tympanic membrane: This appearance indicates a normal, healthy ear and is inconsistent with the symptoms of pain, itching, and discharge described by the client.

D) Thickened and bulging tympanic membrane: This finding is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum, causing it to bulge. However, it does not match the scenario of external ear canal inflammation and discharge following swimming.

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While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

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

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

Correct Answer is B

Explanation

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

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

When evaluating a client's rectal bleeding, which findings should the nurse document?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

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.