EAQ

When a previously healthy 24-year-old client tells the nurse, "I sometimes feel my heart racing or skipping beats", which question would the nurse ask?

"How much caffeine do you consume each day?" Side notes: Caffeine is a commonly used stimulant that causes the heart to become irritable; it can result in tachycardia and premature atrial contractions. In young and healthy individuals it is most likely the cause of palpitations or skipped beats.

The nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. In which way would the nurse document the edema?

4+ Side notes: A grade 4+ indicates an 8-mm depression. A grade of 1+ indicates 2-mm depression. A grade of 2+ indicates a 4-mm depression. A grade 3+ indicates a 6-mm depression.

Where would the nurse place the stethoscope to listen for mitral valve insufficieny (regurgitation)?

The mitral area at the fifth intercostal space at the left midclavicular line (also called the apex of the heart), where mitral valve murmurs can be heard. Sidenotes: The aortic area at the second intercostal space to the right of the sternum is where aortic valve murmurs are best heard. The pulmonic area at the second intercostal space to the left of the sternum best reflects problems of the pulmonic valve. The area at the third intercostal space just to the left of the sternum is over the right main bronchus and is used to assess bronchvesicular breath sounds.

Which action would the nurse take for a client whose right radial pulse is weak and thready?

Assessing all peripheral pulses, assessing and comparing both radial pulses, asking a second nurse to assess the client's pulses, assessing for edema or other issues that may be restricting peripheral blood flow, and observing for pallor/skin temperature differences distal to the weak pulse.

Which client in the emergency department would the nurse assess first?

Client with chest pressure and ST segment elevation on the electrocardiogram. Side notes: The client with chest pressure and ST segment elevation on the electrocardiogram will need emergency treatment for ST segment elevation myocardial infarction (STEMI), including transport to the cardiac catheterization laboratory for percutaneous coronary intervention within 90 minutes, and should be seen first.

Which significance would the nurse associate with the procedure depicted in the figure? (A nurse is assessing the pulse on the ulnar side of the wrist)

Evaluating arterial insufficiency Side notes: The nurse is assessing the ulnar pulse which helps to evaluate arterial insufficiency to the hand.

When would the nurse observe a client to assess their level of functioning?

During mealtime, when preparing medication, and when administering insulin injections. Side notes: An observation of the functional level of the client often occurs during a return demonstration. The nurse may also observe the client while they're eating to determine if the client is able to eat without assistance. The nurse teaches the client how to prepare medication and asks for a return demonstration to assess the client's understanding. The nurse also observes the client administering insulin injections to ensure that the client is able to perform it properly. The observation of functional level differs from the observation during a physical assessment.

Which positioning would be avoided while assessing a client with a history of asthma?

Lateral recumbent Side notes: The lateral recumbent is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position. The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include?

Pain history, including location, intensity, and quality of pain. Also, pain pattern, including precipitating and alleviating factors. Side notes: Vital signs are a secondary assessment related to the initial pain assessment. Elevated blood pressure and heart rate are physiological responses to pain and not a direct evaluation of pain.

How would the nurse document the heart sounds heard when assessing this client?

Pericardial friction rubs. Side notes: Pericardial friction rubs are high pitched, scratchy sounds that are associated with pericarditis and occur as the heart contracts and relaxes within the inflamed pericardial sac; pericardial friction rubs are frequently heard in both systole and diastole.

Which position would the nurse utilize to assess the client's hip joint extension and buttocks?

Prone position Side notes: The dorsal recumbent position is used for an abdominal assessment. The lateral recumbent position is used to assess murmurs. The supine position is used to assess the heart, abdomen, extremities, and pulses.

The nurse prepares to assess a client's heart during a routine health checkup. In which position would the nurse place the client to assess murmurs of the heart?

The client should lie in the lateral recumbent position. Side notes: The supine position is good for assessment of pulse sites. The dorsal recumbent position is good for abdominal assessment. The modified left lateral position is good for assessment of the rectum and vagina.