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 atrophy.

Benign variation.

Cardiac enlargement.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Expected finding is incorrect. While some degree of dullness is expected during percussion of the heart borders due to the presence of solid cardiac tissue, the specific pattern described in the scenario, extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border, suggests an abnormality rather than an expected finding.
Choice B Reason:
Cardiac atrophy is incorrect. Cardiac atrophy refers to a decrease in the size or mass of the heart muscle, resulting in a smaller than normal heart. However, the described findings indicate dullness extending upward, suggesting an enlargement rather than atrophy of the heart.
Choice C Reason:
Benign variation is incorrect. Benign variations in cardiac percussion findings are less likely to produce a pattern of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border. This pattern is more indicative of cardiac enlargement or pathology rather than a benign variation.
Choice D Reason:
Cardiac enlargement is correct. During percussion of the heart borders, dullness indicates solid tissue, such as the heart. The area of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border suggests an enlargement of the cardiac silhouette. This enlargement could be due to various cardiac conditions, such as cardiomegaly (enlarged heart), left ventricular hypertrophy, or other structural abnormalities affecting the heart.

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Correct Answer is C

Explanation

Choice A Reason:
Observing for jugular vein distention while the client is flat in bed is incorrect because jugular vein distention is not directly related to orthopnea. Jugular vein distention may indicate increased central venous pressure, which can occur in conditions such as heart failure, but it is not specific to orthopnea, which is difficulty breathing while lying flat.
Choice B Reason:
Measuring the client's blood pressure when he is lying and standing is incorrect because measuring blood pressure in different positions (lying and standing) is used to assess for orthostatic hypotension, not orthopnea. Orthostatic hypotension refers to a drop-in blood pressure upon standing and is not directly related to difficulty breathing while lying flat.
Choice C Reason:
Asking the client how many pillows he sleeps on at night is correct because orthopnea is characterized by difficulty breathing while lying flat, often relieved by sitting up or propping oneself with pillows. Asking the client how many pillows he sleeps on at night provides valuable information about his sleeping position and potential orthopnea. Clients with orthopnea often need to sleep in a semi-upright position or with multiple pillows to alleviate breathing difficulties.
Choice D Reason:
Auscultating the client's breath sounds while he is supine is incorrect because auscultating the client's breath sounds while he is supine may provide information about lung sounds, but it does not specifically assess for orthopnea. Orthopnea refers to difficulty breathing while lying flat, and the assessment of breath sounds may not directly indicate this condition.

A. Hyperactive bowel sounds. B. A minor variation. C. Normal borborygmic sounds. D. Possible renal artery stenosis.

Correct Answer is D

Explanation

Choice A Reason:
Hyperactive bowel sounds are incorrect. Hyperactive bowel sounds refer to increased or loud gurgling noises heard during auscultation of the abdomen, which may indicate increased intestinal motility or bowel obstruction. These sounds are typically high-pitched and occur in various abdominal quadrants, rather than specifically in the upper midline area.
Choice B Reason:
A minor variation is incorrect. A minor variation in abdominal sounds may occur and could be considered normal. However, a low-pitched blowing sound in the upper midline area is not typically categorized as a minor variation but rather as an abnormal finding that warrants further investigation.
Choice C Reason:
Normal borborygmic sounds is incorrect. Borborygmic refers to the normal rumbling or gurgling sounds produced by the movement of gas and fluid in the intestines. While borborygmic sounds may be heard during abdominal auscultation, they are typically described as high-pitched and occur in various abdominal quadrants, not specifically in the upper midline area. Therefore, they are not likely to be the indication of the finding described in the scenario.
Choice D Reason:
Possible renal artery stenosis is correct. Renal artery stenosis is a condition characterized by the narrowing of one or both renal arteries, which can lead to reduced blood flow to the kidneys. When auscultating the abdomen, a low-pitched blowing sound (bruit) heard over the upper midline area could indicate turbulence of blood flow in the renal arteries. This bruit is typically associated with renal artery stenosis and reflects the increased velocity of blood passing through a narrowed arterial lumen. Identifying a renal artery bruit during abdominal auscultation warrants further investigation, such as imaging studies or referral to a specialist for evaluation and management of renal artery stenosis.

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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?

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Naxlex Comprehensive Predictor Exams

During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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