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Which of the ff symptoms is observed in the client with Right Sided Heart Failure?
- A. Dependent pitting edema
- B. Orthopnea
- C. Exertional dyspnea
- D. Hemoptysis CARING FOR CLIENTS UNDERGOING CARDIOVASCULAR SURGERY
Correct Answer: A
Rationale: Rationale: Right-sided heart failure leads to fluid backup in the body causing dependent pitting edema due to fluid accumulation in the lower extremities. Orthopnea and exertional dyspnea are typically seen in left-sided heart failure. Hemoptysis is associated with conditions like pulmonary embolism or lung cancer, not right-sided heart failure. Therefore, the correct answer is A as it directly correlates with the symptoms of right-sided heart failure.
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A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information provided by the patient, such as their feelings, perceptions, and symptoms. In this case, the patient describing excitement about discharge is subjective as it is based on their personal experience. The other options (A, B, D) are objective data as they can be measured or observed directly without interpretation. The patient's temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. Therefore, only choice C fits the definition of subjective data in a nursing assessment.
Mrs. Diwa has been diagnosed with systemic lupus erythematosus, the nurse upon assessment can expect to find which of the following?
- A. dysphagia
- B. dryness or itching of genitalia
- C. decreased visual acuity or blindness
- D. abnormal lung sounds
Correct Answer: D
Rationale: The correct answer is D because systemic lupus erythematosus can lead to inflammation in the lungs, causing abnormal lung sounds. Dysphagia (choice A) is not typically associated with lupus. Dryness or itching of genitalia (choice B) is more characteristic of conditions like yeast infections or dermatitis. Decreased visual acuity or blindness (choice C) is not a common manifestation of lupus. Abnormal lung sounds (choice D) are commonly seen in lupus patients due to inflammation and possible lung involvement.
The nurse understands that an anaphylactic reaction is considered which of the following types of hypersensitivity reactions?
- A. Type I
- B. Type III
- C. Type II
- D. Type IV
Correct Answer: A
Rationale: The correct answer is A: Type I hypersensitivity reaction. In Type I hypersensitivity, anaphylactic reactions involve immediate IgE-mediated responses to allergens, leading to histamine release and potentially life-threatening symptoms. This type of reaction is characterized by rapid onset and systemic involvement. Choices B, C, and D are incorrect because Type III reactions involve immune complex deposition leading to inflammation (B), Type II reactions involve cytotoxic antibodies targeting cells (C), and Type IV reactions involve delayed cell-mediated responses (D).
The first thing to do for a nurse when an accident occurs is to find out if patient is conscious so that she could:
- A. Reassure the patient
- B. Call relatives
- C. Bring patient immediately to the hospital
- D. Call a doctor
Correct Answer: A
Rationale: The correct answer is A: Reassure the patient. The first priority in any accident scenario is to ensure the patient's safety and well-being. By checking if the patient is conscious, the nurse can assess their immediate condition and provide reassurance to alleviate any distress or anxiety. This step establishes communication and trust, allowing for further assessment and appropriate actions to be taken. Calling relatives (B) may be important but not the immediate first step. Bringing the patient immediately to the hospital (C) is premature without assessing the patient first. Calling a doctor (D) can be done after assessing the patient's condition.
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To prevent respiratory obstruction
- C. To help the client drink fluids
- D. To prevent excessive bleeding
Correct Answer: B
Rationale: The correct answer is B: To prevent respiratory obstruction. An ice collar is used to reduce swelling and inflammation, which can help prevent the abscess from compressing the airway and causing respiratory obstruction. This is crucial in cases of peritonsillar abscess to ensure the client's airway remains patent. Choices A, C, and D do not directly address the primary concern of preventing respiratory obstruction in this context.