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A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client's admitting diagnosis?
- A. An enlarged, distended abdomen.
- B. Crackles in the bases of both lungs.
- C. Jugular vein distension.
- D. Peripheral edema.
Correct Answer: B
Rationale: The correct answer is B. Crackles in the bases of the lungs are indicative of fluid accumulation, which is common in left-sided heart failure. In left-sided heart failure, the heart is unable to effectively pump blood from the lungs to the rest of the body, leading to a backup of fluid in the lungs. This results in crackles heard on auscultation. Choices A, C, and D are not specific to left-sided heart failure. An enlarged, distended abdomen may indicate ascites or liver congestion. Jugular vein distension is more commonly associated with right-sided heart failure, and peripheral edema is a sign of fluid accumulation in the tissues, which can occur in both types of heart failure but is not as specific to left-sided heart failure as crackles in the lungs.
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A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment finding is most often associated with hyperthyroidism?
- A. Periorbital edema.
- B. Atrophied thyroid gland.
- C. Increased pulse rate.
- D. Diarrhea stools.
Correct Answer: C
Rationale: Increased pulse rate is commonly associated with hyperthyroidism due to the increased metabolic rate. Periorbital edema (Choice A) is more commonly associated with conditions like nephrotic syndrome or heart failure, not hyperthyroidism. Atrophied thyroid gland (Choice B) is not typically an assessment finding for hyperthyroidism as the gland is usually enlarged in this condition. Diarrhea stools (Choice D) can occur in hyperthyroidism, but it is not the most common assessment finding associated with the condition.
In the change-of-shift report, the nurse is told that a client has a Stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?
- A. Shallow open ulcer with a red-pink wound bed.
- B. A deep pocket of infection and necrotic tissues.
- C. An area of erythema that is painful to touch.
- D. Visible subcutaneous tissue with sloughing.
Correct Answer: A
Rationale: A Stage 2 pressure ulcer typically presents as a shallow open ulcer with a red-pink wound bed. This appearance is characteristic of a Stage 2 pressure ulcer where there is partial thickness skin loss involving the epidermis and possibly the dermis. Choice B, a deep pocket of infection and necrotic tissues, is more indicative of a Stage 3 or Stage 4 pressure ulcer where the ulcer extends into deeper tissue layers. Choice C, an area of erythema that is painful to touch, is more commonly seen in early-stage pressure ulcers such as Stage 1. Choice D, visible subcutaneous tissue with sloughing, is characteristic of a more severe stage of pressure ulcer beyond Stage 2.
What is the most common symptom of gastroesophageal reflux disease (GERD)?
- A. Heartburn.
- B. Nausea.
- C. Abdominal pain.
- D. Vomiting.
Correct Answer: A
Rationale: The correct answer is A: Heartburn. Heartburn is the most common symptom of GERD as it occurs due to the reflux of stomach acid into the esophagus. This leads to a burning sensation in the chest that can worsen after eating, lying down, or bending over. Choice B, Nausea, is not typically the most common symptom of GERD, although it can occur in some cases. Choice C, Abdominal pain, is not a primary symptom of GERD and is more commonly associated with other gastrointestinal conditions. Choice D, Vomiting, is also not the most common symptom of GERD, although it can occur in severe cases or as a result of complications.
The client with chronic renal failure is receiving education on managing fluid intake. Which of the following statements by the client indicates a need for further teaching?
- A. I can drink as much water as I want.
- B. I should increase my intake of high-sodium foods.
- C. I can skip a dialysis session if I feel tired.
- D. I can eat whatever I want as long as I take my medications.
Correct Answer: C
Rationale: Choice C is the correct answer. Clients with chronic renal failure should not skip dialysis sessions, as this can lead to serious complications. Dialysis is crucial for managing fluid and electrolyte balance in these clients. Choice A is incorrect because clients with renal failure often have fluid restrictions. Choice B is incorrect as high-sodium foods can worsen fluid retention in clients with renal failure. Choice D is incorrect because dietary restrictions are important in managing chronic renal failure, and eating whatever one wants can lead to further complications.
When providing care for an unconscious client who has seizures, which nursing intervention is most essential?
- A. Ensure oral suction is available.
- B. Maintain the client in a semi-Fowler's position.
- C. Provide frequent mouth care.
- D. Keep the room at a comfortable temperature.
Correct Answer: A
Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.