The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" On what understanding does the nurse base a response?
a. Clubbing occurs as a result of untreated congestive heart failure.
b. Clubbing occurs as a result of a left-to-right shunting of blood.
c. Clubbing occurs as a result of decreased cardiac output.
d. Clubbing occurs as a result of chronic hypoxia.
ANS: D
Clubbing of the fingers develops in response to chronic hypoxia.
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The nurse performing an assessment of the client's abdomen uses which of the four techniques of examination in order to collect data?
1. Inspection and auscultation 2. Inspection, auscultation, and palpation 3. Inspection, auscultation, palpation, and percussion 4. Auscultation, percussion, and inspection
A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer?
a. Cholesterol b. Serum lipase c. Carcinoembryonic antigen d. Xylose absorption
A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching?
a. "Foods high in vitamin A and vitamin C are important." b. "I'll have to cut down on the amount of bacon I eat." c. "I'm so glad I don't have to give up my juicy steaks." d. "Vegetables, fruit, and high-fiber grains are important."
Ana is admitted to the medical surgical floor for severe weight loss. Her diagnosis is anorexia nervosa. She is 16 and looks about 8. Her daily intake is about eight cans of diet soda. Your initial nursing goal is:
A. Establish trust. B. Request nutritional supplements from Dietary. C. Explore with her the rationale for refusing to eat. D. B and C