An infant has a continuous machine-type murmur best heard at the left upper sternal border throughout systole and diastole. The healthcare professional suspects a congenital heart disorder. What other assessment finding is inconsistent with the professional’s knowledge about this disorder?
a. Bounding pulses
b. Active precordium
c. Thrill on palpation
d. Signs of heart failure
Ans: c. Thrill on palpation
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The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.)
a. Pulse is equal to uncasted limb. b. Patient is aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limb can flex and extend.
The patient has a newly inserted VVI pacemaker set at a demand rate of 70 . What cardiac monitor reading, if found by the nurse, most indicates a pacemaker malfunction?
A) Patient pulse is 75 with no pacing stimuli seen on cardiac monitor. B) Patient pulse is 70 with pacing stimulus seen before each R wave. C) Patient pulse is 65 with no pacing stimuli seen on cardiac monitor. D) Patient pulse is irregular with pacing stimuli seen before some R waves.
Which of the following nursing interventions would be most likely to facilitate effective communication with a hearing-impaired client?
A) Ask the client to repeat what was said in order to evaluate understanding. B) Stand directly in front of the client to facilitate lip reading. C) Reduce environmental noise and distractions before communicating. D) Raise the voice to project sound at a higher frequency.
Which statement would be the most therapeutic initially when interviewing an adolescent who attempted suicide in the school bathroom?
a. "Can you tell me what you were thinking that caused you to attempt suicide?" b. "It appears that you were really interested in letting your classmates know you were angry.". c. "If you are willing to discuss the reasons you wanted to die, I'm certainly willing to listen to you.". d. "How do you feel I can help you, since most suicide attempts are really cries for help?"