The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which assessment finding indicates a potential complication and requires the nurse's immediate atten-tion?
a. Distended neck veins
b. Left lower quadrant tenderness
c. Urinary output of 40 mL/hr
d. Excessive coughing
A
Cor pulmonale is enlargement of the right side of the heart as a result of pulmonary hypertension caused by constriction of the pulmonary vessels in response to hypoxia. Constant hypoxia sti-mulates erythropoiesis, with resulting polycythemia and increased viscosity of blood. Eventually, right-sided heart failure causes systemic venous congestion which manifests with distended neck veins. The patient would experience right upper quadrant tenderness from an engorged liver. Urinary output of 40 mL/hr is normal. Excessive coughing does not indicate an urgent complica-tion.
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The nurse is performing a circulatory system assessment with a client. Which finding suggests that the client has a total arterial occlusion?
1. The extremity has full and bounding pulses. 2. The client complained of itchy skin. 3. The extremity suddenly became white, cold, and painful. 4. The client experiences transient loss of sensation in an extremity.
A patient reports experiencing vulvar pruritus. Which assessment factor may indicate that the patient has an infection caused by Candida albicans?
A) Cottage-cheese-like discharge B) Yellow-green discharge C) Gray-white discharge D) Discharge with a fishy odor
A patient has an area of rough, thickened, hardened epidermis. What should the nurse suspect as the reason for this skin lesion?
1. chronic dermatitis 2. athlete's foot 3. ear piercing 4. psoriasis
The preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following statements by the nurse is most likely to stimulate further discussion between the client and the nurse?
1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."