Nokea
A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first?
- A. Evaluate distal capillary refill for delayed perfusion
- B. Check the extremities for bruising and petechiae
- C. Examine the pretibial regions for pitting edema
- D. Palpate the abdomen for tenderness and rigidity
Correct Answer: D
Rationale: Palpating the abdomen helps assess for complications such as peritonitis or worsening ascites.
You may also like to solve these questions
Respiratory distress at birth is mostly caused by:
- A. Diaphragmatic hernia
- B. Meconium aspiration
- C. RDS (respiratory distress syndrome)
- D. Pulmonary hypertension
Correct Answer: C
Rationale: The correct answer is C because RDS is the most common cause of respiratory distress in newborns. The other options (a, b, d, e) are less common causes.
A woman who works as a data entry clerk is concerned as to how recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client?
- A. Use a space heater to keep the workspace warm
- B. Keep hands elevated above the heart to prevent swelling.
- C. Wear tight gloves during work to avoid temperature fluctuations.
- D. Take frequent breaks to improve circulation in the hands.
Correct Answer: A
Rationale: Keeping the hands warm helps prevent vasospasms, which are characteristic of Raynaud's syndrome.
When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, 'visual sensory/perceptual alterations.' This diagnosis is based on which etiology?
- A. Limited eye movement
- B. Decreased peripheral vision
- C. Blurred distance vision
- D. Photosensitivity
Correct Answer: B
Rationale: Open angle glaucoma primarily affects peripheral vision, leading to visual sensory/perceptual alterations.
The most common cardiac dysrhythmia in pediatrics is:
- A. Ventricular tachycardia
- B. Sinus bradycardia
- C. Supraventricular tachycardia
- D. First-degree heart block
Correct Answer: C
Rationale: SVT is the most common dysrhythmia in children.
What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? (Select all that apply.)
- A. Spontaneous cyanosis
- B. Dyspnea
- C. Weakness
- D. Dry cough
Correct Answer: C
Rationale: Indicators of a paroxysmal hypercyanotic episode or a tet episode are spontaneous cyanosis, dyspnea, weakness, and syncope.