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A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?
- A. Epigastric pain that radiates to the back.
- B. Abdominal pain with guarding.
- C. Nausea and vomiting.
- D. Increased bowel sounds in all quadrants.
Correct Answer: A
Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. Abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis but are less specific and may be seen in various other gastrointestinal conditions.
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The healthcare professional is assessing a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most indicative of this condition?
- A. Dependent rubor.
- B. Absence of hair on the lower legs.
- C. Shiny, thin skin on the legs.
- D. Pain in the legs when walking.
Correct Answer: D
Rationale: Pain in the legs when walking (D), known as intermittent claudication, is most indicative of peripheral arterial disease (PAD). While dependent rubor (A), absence of hair (B), and shiny, thin skin (C) are also associated with PAD, they are less specific than intermittent claudication. Intermittent claudication is a hallmark symptom of PAD caused by inadequate blood flow to the legs during exercise, resulting in pain that resolves with rest.
When discussing dietary preferences with a client adhering to a vegan diet, which dietary supplement should the nurse encourage the client to include in the dietary plan?
- A. Fiber
- B. Folate
- C. Ascorbic acid
- D. Vitamin B12
Correct Answer: D
Rationale: Vitamin B12 is an essential nutrient that is predominantly found in animal products. Since individuals following a vegan diet do not consume animal products, they are at a higher risk of vitamin B12 deficiency. Therefore, it is crucial for vegans to include a vitamin B12 supplement in their dietary plan to prevent deficiency-related health issues.
A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?
- A. Amount of support provided by family members
- B. Measurement of pain using a scale of 0 to 10
- C. The ability to perform ADLs
- D. Nonverbal behaviors exhibited when pain occurs
Correct Answer: C
Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs.
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to remove secretions.
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
- C. Remove the suction as quickly as possible.
- D. Insert and remove the suction multiple times to clear secretions.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
- A. 13 ml/hour.
- B. 63 ml/hour.
- C. 80 ml/hour.
- D. 125 ml/hour.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.