A patient with heart failure reports having a cough with frothy sputum and awakening during the night to urinate. Based on this information, what abnormal data might this nurse expect to find during an examination? Select all that apply
a. S4 heart sound
b. Dyspnea
c. Jugular vein distention
d. Pericardial friction rub
e. Edema of ankle and feet at the end of the day
f. S3 heart sound
ANS: B, C, E, F
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A child has recently been diagnosed with leukemia. The child's sibling is expressing feelings of anger and guilt. This reaction by the sibling is:
1. Abnormal; the sibling should be referred to a psychologist. 2. Unusual; the illness doesn't affect the sibling. 3. Unexpected; the cancer is easily treated. 4. Normal; the sibling is affected, too, and anger and guilt are expected feelings.
Which outcome statement is related to Decreased Cardiac Output? Select all that apply
a. No dyspnea or shortness of breath with exertion b. Normal skin color c. Respiratory rate less than 16 breaths/min d. Brisk capillary refill
Two clients are roommates in an inpatient psychiatric unit. Client A, who had been missing her gold locket, notices Client B wearing it several days later. Which behavioral response should the nurse expect Client A to display if she were assertive?
A) Ignore the situation. B) Discuss the situation with her nurse and develop a plan of action. C) Immediately approach Client B and pull the necklace off her neck. D) Offer to wash Client B's clothing for her and then "accidentally" spill bleach in the water.
A mother is concerned because her newborn has lost 8 oz three days after birth. What response by the nurse is appropriate?
A) "Your baby needs to be checked for a viral illness." B) "This is a normal and expected finding." C) "Your baby is probably just dehydrated." D) "You need to give your baby formula since she has lost weight during breast-feeding."