Nokea
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
- A. impaired skin integrity
- B. Alteration in activity tolerance
- C. Impaired tissue perfusion
- D. Alteration in body image
Correct Answer: C
Rationale: Impaired tissue perfusion is the priority because varicose veins, ulcerations, and edema suggest poor blood flow, which can lead to worsening complications. Addressing perfusion improves skin integrity and prevents further deterioration, making it more critical than activity tolerance or body image.
You may also like to solve these questions
A nurse is caring for a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the client's condition?(Select All that Apply.)
- A. D-dimer blood test
- B. Complete blood count (CBC)
- C. CT scan
- D. Chest x-ray
- E. Lung ventilation and perfusion scan (VQ scan)
Correct Answer: A,C,E
Rationale: A D-dimer test measures clot breakdown products in the blood, with elevated levels suggesting the presence of an abnormal blood clot like in PE. A CT pulmonary angiography is the gold standard for diagnosing PE, providing detailed images of the lung's blood vessels. A VQ scan is another diagnostic tool for PE, especially for clients who cannot tolerate contrast dye, as it identifies ventilation-perfusion mismatches suggestive of PE. A CBC is not typically used to diagnose PE, and a chest x-ray is performed to rule out other causes but does not confirm PE.
A nurse is teaching a group of clients about causes for developing hearing loss, which of the following risk factors should the nurse include in the teaching?
- A. Alcohol use disorder
- B. Prolonged exposure to loud noises
- C. Exposure to environmental toxins
- D. Contact with excessive heat
Correct Answer: B
Rationale: Prolonged exposure to loud noises causes noise-induced hearing loss. Environmental toxins can also contribute, but noise exposure is the most direct and common risk factor.
A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
- A. Myopia
- B. Vertigo
- C. Photophobia
- D. Presbycusis
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Slurred speech
- B. Confusion
- C. Pain
- D. Fatigue
Correct Answer: D
Rationale: Fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen-carrying capacity of the blood, leading to tiredness and lack of energy. Slurred speech, confusion, and pain are not typical symptoms unless associated with severe or advanced stages.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
- A. Allergic
- B. Acute pain
- C. Febrile
- D. Hemolytic
Correct Answer: D
Rationale: A hemolytic reaction involves red blood cell destruction, leading to fever, chills, and red-tinged urine due to hemoglobin in the urine, indicating a serious reaction.