Auscultation of a child's heart reveals a loud murmur with a precordial thrill. The nurse documents this as which grade?
A) Grade II
B) Grade III
C) Grade IV
D) Grade V
Ans: C
A grade IV murmur is loud with a precordial thrill. A grade II murmur is soft and easily heard. A grade III murmur is characterized as loud without a thrill. A grade V murmur is characterized as loud, audible without a stethoscope.
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A client asks the nurse how hypertension can lead to heart failure. Which response should the nurse provide the client?
A. "Hypertension increases the resistance in the blood vessels causing the heart to work harder to pump the blood out against the resistance of the arteries." B. "Hypertension limits the ability of the heart to stretch before emptying resulting in the heart working harder to pump the blood out into the arterial system." C. "Hypertension causes resistance in the venous system requiring the heart to work harder to pump the blood forward." D. "Hypertension limits the amount of blood entering the left ventricle increasing the workload of the heart to pump an adequate amount of blood into the circulatory system."
When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for:
A) assessment of tissues. B) increasing circulation. C) promotion of conversation. D) relaxation of muscles.
Assistive devices are used to
A. help the staff in ambulating the patient. B. compensate for problems the patient has with walking. C. keep the patient from walking too fast, which may cause a fall. D. prevent back injuries in health care workers.
J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking
his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. the neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room. What steps will you take to assess J.R.?