Nokea
The nurse is performing a cardiovascular assessment on a client. Which item should the nurse assess to obtain the best information about the client's left-sided heart function?
- A. The status of breath sounds
- B. The presence of peripheral edema
- C. The presence of hepatojugular reflux
- D. The presence of jugular vein distention
Correct Answer: A
Rationale: The client with heart failure may present different symptoms depending on whether the right or the left side of the heart is failing. The assessment of breath sounds provides information about left-sided heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-sided heart function.
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A home care nurse assesses an older client's functional status and ability to perform activities of daily living (ADLs). What is the focus area of the nurse's assessment?
- A. Everyday routines
- B. Self-care activities
- C. Household management
- D. Endurance and flexibility
Correct Answer: B
Rationale: To evaluate the client's functional status, the nurse assesses the client's ability to perform self-care or ADLs, including bathing, toileting, ambulating, dressing, and feeding. Everyday routines, household management, and physical condition are not components of functional status.
The nurse prepares to administer a continuous intravenous (IV) infusion through a peripheral IV to a dehydrated client. Which priority assessment should the nurse obtain before initiating the IV infusion?
- A. Daily body weight
- B. Serum electrolytes
- C. Intake and output records
- D. Identifying the client's dominant side
Correct Answer: A
Rationale: The nurse obtains the client's baseline body weight as a priority before beginning the IV infusion because body weight is a sensitive and specific indicator of fluid volume status when body weights are compared on a daily basis. This means that as a client receives or accumulates fluid, body weight quickly and proportionately increases and vice versa. The remaining options may also be reasonable assessments to complete before initiating an IV infusion. However, intake, output, and serum electrolytes are potentially affected by more confounding factors; thus, they are less specific and sensitive to fluctuations in body fluid. Determining the client's dominant side assists in deciding a site for inserting the initial IV catheter, but it provides no information about fluid volume status.
On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation should the nurse expect to note?
- A. Palpitations
- B. A cardiac dysrhythmia
- C. A generalized skin rash
- D. Enlarged and inflamed joints
Correct Answer: D
Rationale: Stage III Lyme disease develops within a month to several months after initial infection. It is characterized by arthritic symptoms such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. A rash occurs during stage I, and cardiac and neurological dysfunction occur during stage II.
The nurse reviews the record of a client who is receiving external radiation therapy and notes documentation of a skin finding as moist desquamation. Which finding on assessment of the client should the nurse expect to observe?
- A. A rash
- B. Dermatitis
- C. Reddened skin
- D. Weeping of the skin
Correct Answer: D
Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. A rash, dermatitis, and reddened skin may occur with external radiation, but these conditions are not described as moist desquamation.
A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?
- A. Bruising behind the ear
- B. The presence of epistaxis
- C. A bruised periorbital area
- D. An edematous periorbital area
Correct Answer: A
Rationale: The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.