A nurse is performing a physical assessment on a patient taking a beta blocker. The patient complains of shortness of breath and has respirations 28/minute, BP 162/90, P 88/minute, and crackles on auscultation
The nurse understands that these signs and symptoms are consistent with which of the following health alterations? a. Pneumonia
b. Left-sided heart failure
c. Pulmonary embolus
d. Right-sided heart failure
B
The signs and symptoms describe left-sided heart failure, in which the blood normally handled by the left ventricle and forced out through the aorta into the body backs up into the lungs, pro-ducing respiratory or lung signs and symptoms.
The patient's signs and symptoms are not indicative of pneumonia.
The patient's signs and symptoms are not indicative of a pulmonary embolus.
The patient's signs and symptoms are consistent with left-sided heart failure, not right-sided heart failure, which would present with more systemic signs and symptoms, such as jugular vein distension, ascites, pitting edema, hepatomegaly, and splenomegaly, among others.
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The nurse is observing a 4-year-old child playing in the play room, and determines the child is meeting normal developmental milestones when the child:
1. Eats with her fingers. 2. Draws a picture of a person with three parts. 3. Ties her shoes and buttons her shirt. 4. Can count to four.
The nurse is conducting a class on human sexual response. The participants have understood the education when they identify that, during the excitement phase of the sexual response, the man may experience what?
A) Nipple erection B) Hypotension C) Bradycardia D) Decreased blood flow to genitals
A young male patient is diagnosed with early stage Buerger's disease. What assessment finding does the nurse expect to find in the patient's record?
a. Claudication of the arch of the foot b. Intolerance of warm environments c. Dizziness and lightheadedness d. Pain in the lower back with ambulation
Because you are concerned about possible smoke inhalation, what will you monitor for
in A.N.? What will be an ideal response?