Nokea
A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?
- A. Atrial gallop
- B. Ventricular gallop
- C. Closing of the atrioventricular valves
- D. Closing of semilunar valves
Correct Answer: B
Rationale: The correct answer is B: Ventricular gallop. An S3 heart sound is indicative of rapid ventricular filling during diastole, which is commonly associated with heart failure. This sound occurs during the early phase of diastole when the ventricles are filled rapidly due to increased pressure in the atria. The S3 sound is heard immediately after S2 (closure of semilunar valves) when blood is rushing into the ventricles. Atrial gallop (choice A) is not associated with the S3 sound. The closing of the atrioventricular valves (choice C) is part of the normal heart sounds and does not produce an S3 sound. Similarly, the closing of semilunar valves (choice D) occurs during S2 but does not cause an S3 sound. Therefore, the correct answer is B as it directly relates to the pathophysiology of an S3 heart sound.
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A nurse is caring for a client who is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.
- A. Aromatherapy
- B. Biofeedback
- C. Guided imagery
- D. Yoga
Correct Answer: A
Rationale: Aromatherapy uses essential oils from plants to promote relaxation, improve mood, and support immune function.
A nurse is reinforcing teaching with a client about crutch walking using the swing-through gait. Which of the following statements should the nurse include?
- A. Look down at your feet before moving the crutches.
- B. Place one crutch forward with the opposite foot and then place the second crutch forward with the other foot.
- C. Move both crutches forward, then lift and move your body past the crutches.
- D. Bear your weight against the underarm crutch pads.
Correct Answer: C
Rationale: The correct answer is C: Move both crutches forward, then lift and move your body past the crutches. This statement correctly describes the swing-through gait technique where both crutches are moved forward simultaneously followed by the client lifting and moving their body past the crutches. This technique helps maintain balance and stability during crutch walking. Looking down at your feet before moving the crutches (Choice A) is incorrect as it can cause the client to lose their balance. Placing one crutch forward with the opposite foot and then the second crutch forward with the other foot (Choice B) is the incorrect description of the swing-to gait technique. Bearing weight against the underarm crutch pads (Choice D) is incorrect as it can cause discomfort and potential nerve damage.
A nurse is reinforcing teaching with an older adult client. Which of the following strategies should the nurse use?
- A. Incorporate teaching needs into one daily session.
- B. Emphasize visual and auditory teaching techniques.
- C. Minimize distractions by closing the door to the room.
- D. Begin with the most difficult learning tasks.
Correct Answer: B
Rationale: The correct answer is B: Emphasize visual and auditory teaching techniques. Older adults may have sensory impairments, so utilizing visual and auditory cues can enhance learning. Visual aids like charts and diagrams, along with verbal explanations, can cater to different learning styles. This approach promotes better retention and understanding.
Incorrect options: A: Incorporating teaching needs into one daily session may overwhelm the older adult. C: Closing the door may create a sense of isolation. D: Beginning with the most difficult tasks can be discouraging and hinder learning progress.
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of a latex allergy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply an elastic bandage to a cut.
- B. When cleaning, I like to use dishwashing gloves.
- C. On my son's birthday I plan to buy balloons.
- D. I will use ink pens for writing.
Correct Answer: D
Rationale: The correct answer is D: "I will use ink pens for writing." This statement indicates an understanding of the teaching because ink pens do not contain latex, thus reducing the risk of exposure for someone with a latex allergy. Elastic bandages (choice A) typically contain latex, dishwashing gloves (choice B) may contain latex, and balloons (choice C) are commonly made of latex, all of which could trigger an allergic reaction. Therefore, using ink pens for writing is the safest choice to avoid latex exposure.
A nurse is assisting an older adult client plan an exercise regimen. Which of the following activities should the nurse encourage the client to avoid?
- A. Stretching
- B. Running
- C. Resistance training
- D. Aerobic exercises
Correct Answer: B
Rationale: The correct answer is B: Running. Older adults may have joint issues, reduced bone density, or balance problems which could be exacerbated by the high impact nature of running. Encouraging the client to avoid running can help prevent injuries. Stretching (A) helps maintain flexibility, resistance training (C) improves strength, and aerobic exercises (D) enhance cardiovascular health, all of which are beneficial for older adults.