The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope. The nurse hears a soft, continuous humming sound
The nurse suspects that dysfunction of which of the following organs ultimately may have resulted in the production of this sound? 1. Stomach
2. Spleen
3. Pancreas
4. Liver
4
Rationale 1: Dysfunction in the client's stomach did not result in this type of sound.
Rationale 2: Dysfunction in the client's spleen most likely did not result in this type of sound.
Rationale 3: Dysfunction in the client's pancreas did not result in this type of sound.
Rationale 4: The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion.
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A client with Addison's disease has a blood glucose level above 80 mg/dL 30 minutes after receiving 15 g of carbohydrates for symptoms of hypoglycemia. Which of the following would the nurse do now?
A) Inform the physician immediately. B) Give the client milk and graham crackers. C) Instruct the client to remain in bed. D) Check the client's blood glucose level before each meal.
The nursing instructor is going over laboratory results for HIV/AIDS patients
The instructor tells the students that upon interpretation of a patient's laboratory results, the nurse should recognize that a patient with HIV is considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what? A) 200 cells/mm3 of blood B) 300 cells/mm3 of blood C) 400 cells/mm3 of blood D) 500 cells/mm3 of blood
What action by the 75-year-old would indicate that an appropriate action has been taken to combat reduced stamina?
a. Moving his home office to a downstairs location b. Using public transportation rather than driving his own car c. Tilling the garden plot with a motor-driven tiller d. Visiting the senior center twice in 1 week to play dominoes
The nurse has tested a client's sense of smell. Which cranial nerve should the nurse document the findings?
A. I. B. II. C. III. D. IV.