The nurse performing an admission assessment of a 36-year-old client with cardiac valve disease would know the most relevant fact is that the client has
a. a childhood history of rheumatic fever.
b. a recent rash on the upper extremities.
c. allergies to shellfish.
d. been a smoker for the last 3 years.
A
A childhood history of rheumatic fever is associated with structural mitral valve disease.
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A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client?
A) Risk for Infection B) Impaired Spontaneous Ventilation C) Risk for Acute Confusion D) Decreased Cardiac Output
The nurse tells the client that his newly created permanent ileostomy:
1. Will initially produce dark green fecal matter. 2. Will require additional surgery in 2 to 3 months. 3. Was necessary when his condition required a gastroduodenostomy (Billroth I). 4. Should not produce any bloody discharge.
A 28-year-old patient is seen with complaints of diarrhea. Which of the following questions would help the clinician establish the diagnosis of irritable bowel syndrome?
a. Feels relief after a bowel movement b. Sometimes is constipated c. Does not defecate in the middle of the night d. All of the above
A client at 33 weeks' gestation calls the healthcare provider's office and reports she was attempting to nap when she became dizzy and felt faint. Which assessment data is the priority in this situation?
A. History of hyperemesis. B. Dietary intake prior to the episode. C. No additional data is needed as this is an isolated incident. D. The position the client was in during the nap period.