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A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?
- A. Atrial fibrillation
- B. Jugular vein distention
- C. Bradycardia
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Jugular vein distention. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This leads to increased pressure in the heart chambers, causing jugular vein distention due to impaired venous return. A: Atrial fibrillation is a common arrhythmia but not specific to cardiac tamponade. C: Bradycardia is not a typical finding in cardiac tamponade as the body tries to compensate for decreased cardiac output. D: Hypotension can be present but is a late sign and not specific to cardiac tamponade.
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A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my medication with food to increase absorption.
- B. If my heart starts racing
- C. my provider might need to adjust my dosage.
- D. I will stop taking this medication once I feel better.
- E. I should take this medication at night before bed.
Correct Answer: B
Rationale: The correct answer is B because it indicates the client understands the potential side effect of levothyroxine, which is palpitations or a racing heart. This shows awareness of the need to monitor and report adverse effects to the healthcare provider promptly. Taking the medication with food (A) actually decreases its absorption. Dosage adjustments (C) are common in thyroid medication but don't necessarily demonstrate immediate understanding. Stopping the medication once feeling better (D) is incorrect as levothyroxine is usually a lifelong treatment. Taking medication at night (E) is not crucial for levothyroxine as long as it is taken consistently.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
- A. Monitor urine output.
- B. Assess level of consciousness.
- C. Check ABGs.
- D. Monitor for signs of withdrawal.
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (D) is important but not as urgent as assessing respiratory status.
A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: The correct answer is C: Increase water intake and use bulk-forming laxatives. This is because increasing water intake helps soften stool, making it easier to pass, and bulk-forming laxatives add bulk to stool, aiding in bowel movements for individuals with IBS-C. Stimulant laxatives (A) can lead to dependency and worsen symptoms. Avoiding fiber-rich foods (B) can exacerbate constipation. Eating a low-carbohydrate diet (D) may not directly address the constipation associated with IBS-C.
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowlers position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. This is crucial post total hip arthroplasty to prevent dislocation. Abduction helps keep the hip joint stable and reduces the risk of the prosthesis slipping out of place. Choices B, C, and D are incorrect. High Fowler's position (B) is not necessary for this specific postoperative care. Crossing legs at the ankles (C) can lead to hip dislocation. Having the client bend forward at the waist (D) can also increase the risk of dislocation.