Which is an expected finding of a client's cardiovascular assessment of the fifth intercostal space at the midclavicular line?
1. S3
2. PMI
3. Murmur
4. Visible pulsations
2
2. The nurse expects to find the point of maximal impulse at the fifth intercostal space at the midclavicular line because this is where the left ventricle is the closest to the chest wall. The nurse follows palpation of the PMI with auscultation of the apical pulse. If the client's heart is dilated or hypertrophic, the PMI shifts to the left toward the anterior axillary line.
1, 3, and 4. S3 or murmur auscultated near any heart valve is generally abnormal along with visible pulsations (called a lift or heave) coming from the heart.
You might also like to view...
Alcohol diminishes the effects of what type(s) of medications? (Select all that apply.)
a. Oral hypoglycemic c. Anticonvulsants b. Anticoagulant d. Tricyclic antide-pressants
The nurse is assessing the gross motor skills of an 8-year-old boy. Which of the following interview questions would facilitate this assessment?
A) "Do you like to do puzzles?" B) "Do play any instruments?" C) "Do you participate in any sports?" D) "Do you like to construct models?"
Information is defined as which of the following?
1. The management and processing of facts 2. Interpreted data 3. A collection of numbers, characters, or facts that are needed for analysis and possible action 4. A synthesis of data derived from several sources to produce a single concept or idea
Which assessment is most relevant to the care of an infant with dehydration?
a. Temperature, heart rate, and blood pressure. b. Respiratory rate, oxygen saturation, and lung sounds. c. Heart rate, sensorium, and skin color. d. Diet tolerance, bowel function, and abdominal girth.