Nokea
A student nurse asks the RN about the clinical manifestations of a thoracic aortic aneurysm. Which of the following findings should the nurse discuss? (Select all that apply).
- A. Shortness of breath
- B. Difficulty swallowing
- C. Upper chest pain
- D. Diaphoresis
- E. Cough
- F. Hoarseness
Correct Answer: A,B,C,E,F
Rationale: These reflect compression of adjacent structures (trachea, esophagus, recurrent laryngeal nerve) by the aneurysm.
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A client is being admitted to the emergency department with a possible dissecting abdominal aortic aneurysm. Which of the following clinical manifestations are not signs and symptoms of hypovolemic shock?
- A. Nausea and faintness
- B. Neurologic deficits and apprehension
- C. Hypertension and tachypnea
- D. Diaphoresis and oliguria
Correct Answer: C
Rationale: Hypertension is not typical in hypovolemic shock (hypotension is expected).
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.
A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?
- A. A headache is an indication of an allergy to the medication.
- B. A headache is an expected adverse effect of the medication.
- C. A headache is likely due to the anxiety about the chest pain.
- D. A headache indicates tolerance to the medication.
Correct Answer: B
Rationale: Headaches are a common side effect of nitroglycerin due to its vasodilating effects on cerebral arteries.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.
A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3 18, and PaCO2 36. Which of the following conditions should the nurse anticipate when interpreting these findings?
- A. Metabolic alkalosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Respiratory acidosis
Correct Answer: C
Rationale: Low pH with low HCO3 indicates metabolic acidosis with appropriate respiratory compensation.