The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture?
a. Gallop rhythm
b. Murmur
c. S1 heart sound
d. S3 heart sound
B
The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.
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The nurse is preparing to auscultate the left apex of a patient's lung. Where will the nurse place the stethoscope to make this assessment?
2. A) Location 1 B) Location 2 C) Location 3 D) Location 4
An 11-year-old boy with a tibia shaft fracture presents for his first follow-up visit after an injury. He is placed into a non-weight bearing, long leg cast with instructions about cast care
Your knowledge about cast care reveals that you should include which of the following statements in your instructions? 1. Keep the cast clean and dry, do not insert objects into the cast, and call the doctor if the cast becomes loose, cracked, or ill fitting. 2. You may take a shower in the cast, just don't put weight on it. 3. It's okay to put coins down the cast. 4. Do not call the office for a foul smell or skin irritation.
Which question relates to the affective domain of learning?
A) "Do I really feel confident in preparing and delivering intravenous medications?" B) "What feeling would I be experiencing if my child was about to be taken into surgery?" C) "Would I be less nervous about taking the 'fluid and electrolytes' test if I studied more?" D) "How can I best apply this information about acute depression to my nursing practice?"
You are preparing a resident for a physical exam. Which is correct?
a. You need to be sensitive to the person's fears and concerns. b. You must respect personal choice by let-ting the person choose what to wear. c. You explain why the exam is needed and what to expect. d. You obtain the person's informed consent.