The nurse auscultates the client's heart sounds and notes a low pitch in late diastole over the apex of the heart that increases with elevation of the legs. What does the nurse document?
1. S1
2. S2
3. S3 ventricular gallop
4. S4 atrial gallop
4
Rationale: The sound heard by the nurse is an S4 atrial gallop, often heard in clients with poorly controlled hypertension.
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The nurse is creating a care plan for a patient taking a selective serotonin reuptake inhibitor (SSRI). What would be an appropriate nursing diagnosis for this patient?
A) Risk for infection B) Establish suicide precautions C) Disturbed thought processes related to central nervous system (CNS) effects of medication D) Dysfunctional Family Processes
A client is diagnosed with neurocognitive disorder caused by Lewy body disease. What should the nurse expect when assessing this client? (Select all that apply.)
1. Depression 2. Increased thirst 3. Visual hallucinations 4. Loss of spontaneous movement 5. Frequent episodes of drowsiness and staring into space
A new nurse is friendly and talkative and often tells her patients about her personal life as a way to make friends with them. The manager is counseling her because of recent complaints from these patients that she is unprofessional
Which statement by the manager best summarizes the problem? a. "Be careful about sharing information; patients can use it against you." b. "It is unprofessional to divulge any personal information to your patients." c. "Personal disclosure can be helpful only if it is in the patient's best interest." d. "You are not here to make friends with patients; you are a professional nurse."
A 19-year-old woman comes to the gynecologist's office. When the nurse asks the reason for this visit, the client explains that she has never had a menstrual period, and that she is concerned there might be something wrong
What is the diagnosis that the physician is most likely to make based on this information? 1. Primary dysmenorrhea 2. Secondary infertility 3. Primary amenorrhea 4. Secondary amenorrhea