Nokea
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
- A. Anorexia
- B. Weight gain
- C. Distended abdomen
- D. Dyspnea
Correct Answer: D
Rationale: Dyspnea is a hallmark symptom of left-sided heart failure due to pulmonary congestion from blood backing up into the lungs.
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The healthcare provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
- A. I was an intravenous drug abuser in the past and shared needles.
- B. I ate shellfish about 2 weeks ago at a local restaurant.
- C. I had a blood transfusion 30 years ago after major abdominal surgery.
- D. I have had unprotected sex with multiple partners.
Correct Answer: B
Rationale: Hepatitis A is typically transmitted through contaminated food/water - shellfish is a known source.
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?
- A. Tenderness in the left upper abdomen
- B. Ecchymosis of the extremities
- C. Pale-colored urine
- D. Fatty stools
Correct Answer: D
Rationale: Fatty stools (steatorrhea) occur with common bile duct obstruction because bile cannot reach the intestine to emulsify fats.
A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
- A. Place a cool cloth on the forehead.
- B. Elevate the head of the bed 30 degrees.
- C. Administer morphine 2 mg IV.
- D. Prepare for a lumbar puncture.
Correct Answer: B
Rationale: Elevating the HOB decreases intracranial pressure which may be causing the headache.
A nurse is admitting a client with a history of duodenal ulcer. To determine if the client's current symptoms are related to this information, the nurse should assess the client for which manifestations of a duodenal ulcer?
- A. Pain relieved by food intake
- B. Pain radiating down the right arm
- C. Nausea and vomiting
- D. Weight loss
Correct Answer: A
Rationale: Pain relief after eating is characteristic of duodenal ulcers as food neutralizes gastric acid temporarily.
A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?
- A. Disequilibrium syndrome
- B. Septicemia
- C. Air embolism
- D. Peritonitis
Correct Answer: A
Rationale: These are classic symptoms of disequilibrium syndrome from rapid fluid/electrolyte shifts during initial dialysis.