The nurse assesses plus 2 pitting edema bilaterally on a patient's lower extremities and adventitious lung sounds upon auscultation. Which of the following do these assessment findings suggest to the nurse?
1. right heart failure
2. abdominal aortic aneurysm
3. peripheral vascular disease or left ventricular dysfunction
4. renal artery stenosis
3
Rationale: Peripheral edema may indicate peripheral vascular disease or left ventricular dysfunction which are both commonly associated with coronary artery disease. Adventitious breath sounds could be caused by fluid backing up into the pulmonary vasculature. This also could be due to left ventricular dysfunction. There is not enough information to determine if the patient is demonstrating right heart failure, an abdominal aortic aneurysm, or renal artery stenosis.
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Which of the following individuals would most likely benefit from health education that emphasizes adherence? A) An older adult who is colonized with methicillin-resistant Staphylococcus aureus (MRSA) B) An 80-year-old man who has a small bowel obstruction C) A 52-year-old woman who has a new diagnosis of multiple sclerosis D) A child who fractured her humerus in a playground accident
With respect to CPR and foreign body airway obstruction procedures, the child should be treated as an adult once:
A) he or she reaches the age of 8 to 10 years. B) resting vital signs are consistent with an adult. C) his or her body weight is estimated at 55 pounds. D) secondary sexual characteristics have developed.
The nurse is using the nursing process to care for a patient with mental illness. At what point of the nurse-patient interaction will the nurse complete the assessment phase of the nursing process?
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A woman is at 42 weeks of gestation. Which of the following medications will be administered to promote cervical ripening?
A) Calcium gluconate B) Magnesium sulfate C) Terbutaline (Brethine) D) Dinoprostone (Cervidil)