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The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document?
- A. Pericardial friction rub
- B. S1, S2, no adventitious sounds
- C. S3 extra heart sound
- D. Systolic murmur
Correct Answer: C
Rationale: An S3 heart sound is commonly associated with heart failure due to fluid overload and ventricular dysfunction.
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A behavior modification program is planned for an adolescent who exhibits disruptive behavior. Which action by the nurse is most consistent with a behavior modification program?
- A. Punish the client if she becomes disruptive.
- B. Give the client extra privileges when she is not disruptive for a day.
- C. Remind the client what she is supposed to do at regular intervals.
- D. Ask the client what she sees as good behavior.
Correct Answer: B
Rationale: Positive reinforcement (extra privileges for non-disruptive behavior) aligns with behavior modification, encouraging desired actions. Punishment, reminders, or asking perceptions are less effective.
An adult is admitted with advanced cancer of the GI tract. What question must be included in the admission assessment?
- A. What foods do you like best?
- B. Do you have advance directives?
- C. Do you want CPR if you go into cardiac arrest?
- D. Do you understand the serious nature of your illness?
Correct Answer: B
Rationale: Advanced cancer requires discussion of end-of-life preferences. Asking about advance directives ensures the client's wishes are documented, taking priority over dietary preferences, specific CPR desires, or illness understanding.
A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client, and is aware that gradual emptying is preferred over complete emptying because it reduces the
- A. Potential for renal collapse
- B. Potential for shock
- C. Intensity of bladder spasms
- D. Chance of bladder atrophy
Correct Answer: B
Rationale: Potential for shock. Complete, rapid emptying can cause shock and hypotension due to sudden changes in the abdominal cavity.
The parents of a 2-year-old client ask how they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? Select all that apply.
- A. Follow as many home routines as possible
- B. Organize a visit from a playgroup friend
- C. Sleep in the child's hospital room at night
- D. Take child on regular visits to the playroom
- E. Tell the child they did not cause the illness
Correct Answer: A,C,E
Rationale: Maintaining home routines, parental presence, and reassuring the child about the cause of illness help reduce anxiety and promote coping during hospitalization.
The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.