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When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

A.

Auscultate for any cardiac murmurs

B.

Compare the apical and radial pulse rates

C.

Palpate the quality of the peripheral pulses

D.

Find the point of maximal impulse

E.

Check capillary refill time

Answer and Explanation

The Correct Answer is A

A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.

 

B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.

 

C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.

 

D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.

 

E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.


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View Related questions

Correct Answer is E

Explanation

A. Cutaneous pain refers to pain from the skin and subcutaneous tissues, which is not described here.

B. Parasympathetic pain is not a recognized category of pain.

C. Visceral pain arises from internal organs and does not typically present as sharp, tingling, or numb.

D. Deep somatic pain is related to muscles, joints, and bones and typically does not have the sharp, tingling quality described.

E. Neuropathic pain is characterized by sharp, tingling sensations and numbness, often resulting from nerve damage, which fits the client's description.

Correct Answer is B

Explanation

A. This option incorrectly includes the aortic valve rather than the tricuspid valve in the S1 heart sound.

B. S1 represents the closure of the mitral and tricuspid valves, which occurs at the beginning of ventricular systole and produces the "lub" sound.

C. The pulmonic valve closure is associated with the S2 heart sound, not S1.

D. The closure of the pulmonic and aortic valves occurs in S2, not S1.

E. This combination is incorrect, as S1 is associated with mitral and tricuspid valve closure.

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