The nurse notes an S3 heart sound in a 4-year-old client. Which of the following would be the most appropriate response by the nurse?
Notify the provider immediately
Instruct the child's caretaker the child will likely require additional invasive diagnostic testing to determine the cause for the abnormal heart sound
Document the finding, understanding S3 is a normal finding in pediatrics
Prepare to transfer the client to a high-level care facility
The Correct Answer is C
A. Notify the provider immediately: Immediate notification is indicated for new pathologic findings in adults, but S3 in young children may be physiologic and not an emergency.
B. Tell caretaker child will likely require invasive diagnostic testing: Suggesting invasive testing without further assessment or context is premature for a pediatric S3 that is often benign.
C. Document the finding, understanding S3 is a normal finding in pediatrics: S3 can be a normal (physiologic) heart sound in children and young adults; documentation and routine monitoring is appropriate.
D. Prepare to transfer the client to high-level care: Transfer is not needed solely for an isolated, likely physiologic S3 in a 4-year-old without other concerning signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","G"]
Explanation
A. Rice: Rice is primarily a carbohydrate source and is low in protein relative to the other options; it is not a primary protein choice for promoting wound healing.
B. Beef: Beef is a high-quality, complete protein source that supplies essential amino acids (plus iron and zinc) important for tissue repair.
C. Eggs: Eggs are a complete protein with all essential amino acids and support collagen synthesis and wound healing.
D. Olive oil: Olive oil is a healthy fat and provides calories and some anti-inflammatory benefits but is not a significant protein source.
E. Chicken: Chicken is a lean, high-quality protein source useful for rebuilding tissue and supporting healing.
F. Apples: Apples provide fiber and vitamins but are low in protein; they are not a primary protein source for wound repair.
G. Salmon: Salmon supplies high-quality protein and also provides omega-3 fatty acids, supporting nutrition for healing.
Correct Answer is B
Explanation
A. Vesicular breath sounds: Vesicular sounds are normal, soft, low-pitched breath sounds heard over peripheral lung fields and are not described as coarse or pain-associated.
B. Pleural friction rub: A pleural friction rub is a coarse, grating sound synchronous with respiration and is often associated with pleuritic chest pain, matching this description.
C. Atelectasis: Atelectasis often causes diminished or absent breath sounds and possibly fine crackles during deep breaths, not a coarse sound in rhythm with breathing.
D. Fine rales: Fine rales (crackles) are high-pitched, intermittent popping sounds, usually at end-inspiration, and are not the coarse, pleuritic-synchronous sound described.
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