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 D

Explanation

A. Administer the medications at different times to provide an even blood level: This option is inappropriate given the client's current heart rate. Both atenolol and diltiazem are cardiovascular medications that can further lower heart rate and potentially lead to bradycardia or other complications.

B. Assess the client's blood pressure and if the BP is normal, administer the medications: While it's important to assess blood pressure, both medications can further decrease heart rate. Given the current bradycardia (heart rate of 45 beats/min), administering either medication could exacerbate the issue.

C. Document the pulse rate and administer the medications as prescribed: This option is not appropriate. The pulse rate of 45 beats/minute is significantly below the normal range, and administering medications that can lower heart rate further could pose serious risks.

D. Withhold the medications and reassess the heart rate in 30 minutes: This is the best nursing action. Withholding the medications allows for further evaluation of the client's heart rate, and it ensures that the nurse can prevent potential adverse effects related to the bradycardia.

A. Your blood pressure reflects how strong your heart muscle contracts." B. "If you feel good your medication is working properly" C. "Even if you are feeling good, damage can occur to your heart and kidneys." D. "Have you told your doctor that you are feeling good?"

Correct Answer is C

Explanation

A. Your blood pressure reflects how strong your heart muscle contracts: This statement oversimplifies the complexities of blood pressure and doesn't directly address the client's misunderstanding about the implications of hypertension.

B. "If you feel good your medication is working properly": While this may be true, it fails to convey the importance of monitoring blood pressure, regardless of symptoms. It might lead the client to believe that feeling well means there are no health concerns.

C. "Even if you are feeling good, damage can occur to your heart and kidneys": This response is the most appropriate as it emphasizes that hypertension can cause silent damage over time, even in the absence of symptoms. It educates the client about the potential long-term consequences of uncontrolled hypertension.

D. "Have you told your doctor that you are feeling good?": While it encourages communication, it does not provide useful information or address the client’s misconceptions about hypertension and its risks.

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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

A client is scheduled to receive atenolol 25 mg PO and diltiazem 60 mg PO at 0800. The nurse assesses the client's heart rate as 45 beats/minute and irregular. What is the best nursing action at this time?

Correct Answer is D

Explanation

The client diagnosed with primary hypertension states, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate response?

Correct Answer is C

Explanation

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