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A nurse is reviewing the medical record of a client who has pneumonia. The nurse should plan to have the client lie on his stomach in Trendelenburg position with pillows elevating the right side of his chest to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: This positioning promotes drainage from the posterior right lower lobe by using gravity.
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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.
A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?
- A. Generativity versus stagnation
- B. Identity versus role diffusion
- C. Intimacy versus isolation
- D. Trust versus mistrust
Correct Answer: C
Rationale: The correct answer is C: Intimacy versus isolation. During the stage of Intimacy versus isolation in Erikson's psychosocial development theory, individuals focus on forming deep, meaningful relationships and developing a sense of commitment to others. This stage typically occurs in young adulthood. By establishing relationships with commitment, individuals achieve intimacy and avoid feelings of isolation.
A: Generativity versus stagnation focuses on contributing to society and future generations.
B: Identity versus role diffusion involves developing a sense of self and a coherent identity.
D: Trust versus mistrust occurs in infancy and is about developing a sense of trust in the world.
Overall, C is the correct choice as it aligns most closely with the task of establishing relationships with commitment.
A nurse is collecting data from a client who is receiving intermittent enteral feedings. Which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula?
- A. Hematocrit 42%
- B. Urine specific gravity 1.022
- C. BUN 28 mg/dL
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: BUN 28 mg/dL. An elevated BUN level indicates poor protein metabolism, which could be a sign that the current enteral formula is not being adequately utilized by the client. This could lead to malnutrition or other complications.
A: Hematocrit measures the volume percentage of red blood cells in blood. It is not directly related to enteral feedings.
B: Urine specific gravity reflects hydration status and kidney function, not related to enteral feedings.
D: Sodium level is not specific to enteral feedings.
In summary, an elevated BUN level signifies poor protein metabolism and indicates a need for a change in the enteral formula to better meet the client's nutritional needs.
A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take?
- A. Explore the client's feelings.
- B. Discuss the competency of the surgeon.
- C. Review another individual's similar surgical experience.
- D. Talk with the client's partner.
Correct Answer: A
Rationale: Encouraging the client to express their feelings provides emotional support and helps alleviate anxiety.
A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?
- A. You have nothing to worry about.
- B. Others who have had this procedure have had great results.
- C. Tell me more about your concerns.
- D. Why are you feeling so anxious?
Correct Answer: C
Rationale: The correct response is C: "Tell me more about your concerns." This is the best response because it shows active listening and empathy towards the client's feelings. By encouraging the client to express their concerns, the nurse can address specific fears or worries, providing reassurance and support tailored to the individual's needs. This open-ended question allows the client to share their feelings, leading to better communication and trust between the nurse and client.
Other choices are incorrect because:
A: "You have nothing to worry about." is dismissive and does not acknowledge the client's feelings.
B: "Others who have had this procedure have had great results." may minimize the client's anxiety and not address their specific concerns.
D: "Why are you feeling so anxious?" is a closed-ended question that may put the client on the spot and not facilitate open communication.