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Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
- A. orthopnea
- B. fever
- C. weight loss
- D. calf pain A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET O
Correct Answer: A
Rationale: Orthopnea is a common symptom of congestive heart failure. It is defined as difficulty in breathing when lying flat, which improves when sitting up or standing. This occurs due to the redistribution of blood in the body when changing positions. As fluid accumulates in the lungs in congestive heart failure, lying down increases pressure on the chest and impairs breathing. Therefore, orthopnea is a significant assessment finding that would suggest to the home health nurse that the patient is developing congestive heart failure. Fever, weight loss, and calf pain are not typically associated with congestive heart failure.
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Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
- A. The nurse checks the clients BP every hour
- B. The nurse checks the site and progress of the infusion every hour
- C. The nurse checks the progress of the infusion once a day
- D. The nurse checks the client's pulse rate every hour
Correct Answer: B
Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.
A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:
- A. emergency
- B. urgent
- C. elective
- D. required
Correct Answer: A
Rationale: Appendectomy as a treatment for acute appendicitis is classified as an emergency surgery. Acute appendicitis is considered a medical emergency that requires prompt surgical intervention to prevent complications such as a ruptured appendix, which can lead to peritonitis, a life-threatening condition. In emergency situations, surgery must be done urgently to address the immediate threat to the patient's health. This is in contrast to elective surgeries, which are typically scheduled in advance and do not require immediate attention. In the case described, the patient's symptoms of fever, nausea, vomiting, and vague abdominal pain suggest an acute presentation that necessitates urgent surgical intervention, making it an emergency appendectomy.
A 1-year-old child develops right eye ptosis, miosis, and loss of sweating; you suspect neuroblastoma. The MOST valuable investigation to confirm the diagnosis is
- A. CT scan of the neck and chest
- B. CT scan of the abdomen
- C. CT scan of the brain
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: A
Rationale: CT scan of the neck and chest can help identify a primary neuroblastoma mass in the adrenal gland or sympathetic chain.
Regarding physical growth of middle childhood (6-11 years), all are true EXCEPT
- A. 3-3.5 kg weight increment/yr
- B. 6-7 cm height increment/yr
- C. brain stops myelinization by 8 years
- D. risk for future obesity falls by 6 years
Correct Answer: D
Rationale: Risk for obesity does not necessarily fall by 6 years.
The nurse practitioner assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
- A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
- B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
- C. Weight gain, hypervigilance, hypothermia, and edema of the legs
- D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B
Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs and tissues in the body. The assessment findings listed in option B are more indicative of SLE: