An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

Document in the client's record.

Prepare the client for an echocardiogram.

Notify the healthcare provider.

Limit the client's fluids.

Answer and Explanation

The Correct Answer is A

An S3 heart sound can be a normal finding during pregnancy due to increased blood volume and changes in cardiac output. It is known as a physiological S3 and is considered a benign finding in the absence of other concerning symptoms or signs.

In this case, there is no immediate need for intervention or concern regarding the S3 heart sound. It is not necessary to prepare the client for an echocardiogram or limit the client's fluids based solely on the presence of an S3 heart sound in the absence of other significant symptoms or complications.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale: Misplacing car keys occasionally is a common occurrence and may not necessarily indicate Alzheimer's disease. It can happen to anyone, especially when distracted or in a hurry.

Choice B rationale: Difficulty performing familiar tasks, such as cooking a meal or driving to a familiar location, is an early warning sign of Alzheimer's disease. It indicates changes in cognitive function.

Choice C rationale: Losing sense of time, such as not knowing the date, day of the week, or season, can be an early indicator of Alzheimer's disease. It reflects impairments in temporal orientation.

Choice D rationale: Problems with performing basic calculations, such as managing finances or following a recipe, are early signs of Alzheimer's disease. It shows a decline in cognitive abilities related to numbers and problem-solving.

Choice E rationale: Becoming lost in a usually familiar environment, such as getting disoriented in one's own neighborhood, is a significant early warning sign of Alzheimer's disease. It suggests spatial and memory impairments.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C). B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.

Correct Answer is A

Explanation

A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.

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An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply)?

Correct Answer is ["B","C","D","E"]

Explanation

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Correct Answer is A

Explanation

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