The nurse auscultates a S4 heart sound during the morning assessment of a client. Which additional assessment data would correlate with this finding?

Crackles heard at the lung bases

Dorsalis pedis pulses +1

A pericardial friction rub

Heart rate 50 beats per minute

Answer and Explanation

The Correct Answer is A

A. Crackles heard at the lung bases: An S4 heart sound often indicates left ventricular hypertrophy or decreased compliance of the left ventricle, commonly seen in conditions like heart failure. Crackles in the lungs can suggest pulmonary congestion related to heart failure, making this the most relevant correlation.

B. Dorsalis pedis pulses +1: A weak pulse may indicate peripheral vascular issues, but it doesn't directly correlate with an S4 heart sound.

C. A pericardial friction rub: This is associated with pericarditis and not directly related to the S4 heart sound.

D. Heart rate 50 beats per minute: While bradycardia may be present in various cardiac conditions, it does not specifically correlate with the S4 sound, which is more about ventricular filling pressures.

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Correct Answer is C

Explanation

A. "I should continue to read the labels of foods I select in the grocery store.": This statement is appropriate as reading labels helps the client avoid high sodium and unhealthy fats, which can negatively impact blood pressure.

B. "When I get out of bed in the morning, I should first sit for a few minutes and then stand.": This statement reflects a good understanding of managing potential orthostatic hypotension, which can occur with antihypertensive medications. It indicates awareness of the need to rise slowly to prevent dizziness.

C. "I will be able to stop my anti-hypertensive medication when my blood pressure is normal.": This statement indicates a need for clarification. Many patients believe that once their blood pressure is normal, they can discontinue medication, but hypertension is often a chronic condition that requires ongoing management to maintain blood pressure control.

D. "Keeping my blood pressure under control reduces my risk for a heart attack.": This statement is accurate and demonstrates an understanding of the importance of hypertension management in reducing cardiovascular risk.

A. Avoid needle sticks or other invasive procedures as much as possible. B. Hold all stool softeners and laxatives until otherwise C. Encourage vigorous tooth brushing with a soft bristle toothbrush, D. Obtain a core temperature every 8 hours.

Correct Answer is A

Explanation

A. Avoid needle sticks or other invasive procedures as much as possible: This is the most appropriate action for a client with thrombocytopenia. Since thrombocytopenia involves a low platelet count, the risk of bleeding is increased, and minimizing invasive procedures helps prevent complications.

B. Hold all stool softeners and laxatives until otherwise: This statement is not appropriate. Clients with thrombocytopenia should avoid straining during bowel movements, which can be facilitated by the use of stool softeners or laxatives if necessary.

C. Encourage vigorous tooth brushing with a soft bristle toothbrush: This is not advisable. While using a soft-bristled toothbrush is recommended, vigorous brushing could cause gum bleeding. Gentle oral hygiene practices should be emphasized instead.

D. Obtain a core temperature every 8 hours: While monitoring temperature is important, it is not specific to thrombocytopenia management. Other vital signs may be monitored more frequently, but this action does not directly address the primary concern of bleeding risk.

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The nurse auscultates a S4 heart sound during the morning assessment of a client. Which additional assessment data would correlate with this finding?

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Naxlex Comprehensive Predictor Exams

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

Correct Answer is C

Explanation

Which of the following actions should a nurse plan for when providing care for a client diagnosed with thrombocytopenia?

Correct Answer is A

Explanation

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