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 preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching?
- A. You'll have to remove metal objects such as watches and body jewelry.
- B. Your exposure to radiation will be minimal.
- C. You will not be able to talk to the technician during the procedure.
- D. Unlike an x-ray, the MRI allows you to move around a bit.
Correct Answer: A
Rationale: The correct answer is A: You'll have to remove metal objects such as watches and body jewelry. This is important for MRI safety as the magnetic field can interact with metal objects, causing harm or image distortion. Removing metal ensures the client's safety during the procedure. Choice B is incorrect as MRI does not involve radiation exposure but magnetic fields. Choice C is incorrect as communication with the technician is usually possible through an intercom system. Choice D is incorrect as clients must remain still during an MRI to prevent image blurring.
A nurse is assisting with a presentation at a senior center regarding age-related changes. Which of the following should the nurse include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. With aging, there is a natural decline in muscle mass known as sarcopenia. The nurse should include this because it is a common age-related change that can affect strength and mobility in older adults. Decreased muscle mass can lead to frailty and increased risk of falls. Thickened vertebral disks (B) are not a typical age-related change; instead, they tend to degenerate and become thinner. Decreased chest width (C) is not a significant age-related change and may vary among individuals. Increased force of isometric contractions (D) is not a typical age-related change; in fact, muscle strength tends to decrease with age, leading to reduced force production.
A nurse is caring for a client whose belongings were lost in a hurricane. The client says, 'What's the use in starting over? It will probably happen again.' Which of the following responses should the nurse make?
- A. I am sure everything will work out.'
- B. It appears you are feeling hopeless.'
- C. It is probably not as bad as you think.'
- D. I would not worry about what can't be changed.'
Correct Answer: B
Rationale: Acknowledging feelings of hopelessness is therapeutic and encourages the client to express emotions.
Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
- A. Increased urine output
- B. Adventitious breath sounds
- C. Decreased level of consciousness
- D. Dry crust on the incision line
- E. Oral temperature of 38.3°C (101°F)
Correct Answer: B,C,E
Rationale: Adventitious breath sounds suggest pneumonia, decreased consciousness may indicate sepsis, and fever is a systemic infection response. Increased urine output is not a sign, and dry crust is part of normal healing.