Free Nursing review 2020

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Assessment/Physical exam




A clinic nurse is performing a cardiovascular assessment on a client. In preparing to assess the client's apical pulse, the nurse places the stethoscope over the heart's apex in which of the following positions?

A. At the midline of the chest just below the
xiphoid process.

B. AT the midclavicular line at the fifth left intercostal space.

C. At the midaxillar line on the left side of the chest.

D. Midsternum, equal with the ni**le line.

Answer: B.

RATIONALE:
The heart is located in the mediastinum.
Its apex, or distal end, points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex.

Exam STRATEGY:
Use the process of Elimination. Visualize the anatomical position of the heart to assist in directing you to option 2.

/physical Exam




A nurse has obtained a personal and family history from a client with a neurological disorder. Which of the following factors in the client's history is not associated with added risk for neurological problems?

A. Previous back injury

B.Allergy to pollen

C.History of hypertension

D. History of headaches

Answer: B

Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic disease such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem.

Exam STRATEGY
Focus on the Subject: risk for neurological problems, note the strategic words is not associated. Each of the incorrect options has an actual or a potential neurological association. Allergies indicate a disturbance of the immune system. Review the risks associated with neurological problems if you had difficulty with this question.