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The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first:
- A. Assess for changes in vital signs.
- B. Draw an arterial blood gas.
- C. Evaluate heart sounds with the client leaning forward.
- D. Obtain a 12 Lead electrocardiogram.
Correct Answer: A
Rationale: A new systolic murmur post-myocardial infarction may indicate complications like ventricular septal rupture or mitral regurgitation. Assessing vital signs first helps determine the client's stability and guides further actions.
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A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that:
- A. Some melanomas have a familial component and she should seek medical advice.
- B. Her personal risk is low because most melanomas occur at age 60 or later.
- C. Her personal risk is low because melanoma does not have a familial component.
- D. She should not worry because she did not experience severe sunburn as a child.
Correct Answer: A
Rationale: Melanoma can have a familial component, and a family history increases personal risk. Seeking medical advice for screening and risk assessment is appropriate, especially given her sister's diagnosis.
After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
- A. Monitor for signs and symptoms of hyperthyroidism.
- B. Rest for 1 week to prevent complications of the medication.
- C. Take thyroxine replacement for the remainder of the client's life.
- D. Assess for hypertension and tachycardia resulting from altered thyroid activity.
Correct Answer: C
Rationale: RAI often destroys enough thyroid tissue to cause hypothyroidism, requiring lifelong thyroxine replacement. Monitoring for hyperthyroidism is unnecessary post-treatment, and rest or assessing for hypertension/tachycardia are not primary concerns.
Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the emergency department in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. For which signs and symptoms should the nurse be especially alert?
- A. Infection
- B. Deformity
- C. Shock
- D. None of the above
Correct Answer: C
Rationale: An open fracture increases the risk of infection and deformity, but shock is a critical systemic complication that can develop rapidly due to blood loss or pain, requiring vigilant monitoring.
The client with Hodgkin's disease develops B symptoms. These manifestations indicate which of the following?
- A. The client has a low-grade fever (temperature lower than 100°F [37.8°C]).
- B. The client has a weight loss of 5% or less of body weight.
- C. The client has night sweats.
- D. The client probably has not progressed to an advanced stage.
Correct Answer: C
Rationale: B symptoms in Hodgkin's disease include fever (>38°C), night sweats, and weight loss (>10% of body weight). Night sweats are a hallmark symptom indicating possible disease progression.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.