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Question 1 of 5

The nurse is auscultating the apical pulse over the PMI (point of maximum impact). Which heart sounds would be audible?

Correct Answer: D

Rationale: S1 (mitral/tricuspid closure) and S2 (aortic/pulmonic closure) are normally audible at the PMI. S3 and S4 are less common and indicate pathology.

Question 2 of 5

The doctor has prescribed Claratin (loratidine) for a client with seasonal allergies. The feature that separates Claratin from other antihistamines such as diphenhydramine is that the medication:

Correct Answer: A

Rationale: Loratadine (Claritin) is a second-generation antihistamine that is nonsedating, unlike first-generation antihistamines like diphenhydramine.

Question 3 of 5

A 78-year-old client with a history of diabetes mellitus type 2, GERD, and hypertension is hospitalized with pneumonia and rings the call bell at 11 PM, complaining of being unable to sleep and having 'indigestion' and 'heartburn.' Which of the following initial interventions is most indicated?

Correct Answer: D

Rationale: In an elderly client with comorbidities, indigestion and heartburn may indicate a cardiac event, so assessing cardiac and respiratory status (
D) is the priority. Administering medications (A, B,
C) is secondary.

Question 4 of 5

A 17-year-old adolescent, diagnosed with schizophrenia, is admitted by the nurse to a psychiatric facility. Which behaviors would characterize this diagnosis? Select all that apply.

Correct Answer: A,C

Rationale: Flat affect and hallucinations are hallmark symptoms of schizophrenia. Fast speech or feeling energized may occur but are not specific to this diagnosis.

Question 5 of 5

The nurse has documented a treatment on the wrong client's record. Which of the following methods of indicating the error is correct?

Correct Answer: A

Rationale: A single line through the error with 'error' written above and initialed (
A) maintains transparency while correcting the record. Correction fluid (
B) is unacceptable, multiple lines (
C) obscure the record, and margin notes (
D) are insufficient.

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The nurse caring for a client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
A nurse reviewed a client's progress in smoking cessation, praising the client for being successful but suggesting the client might stop having coffee in the morning since that caused an urge to smoke. Following this session, the client appeared upset and complained that the nurse believed she was doing poorly because she wanted a cigarette with her morning coffee. Which type of cognitive distortion is the client exhibiting?
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