The nurse notes that an 84-year-old male returning from the operating room (OR) after postinguinal hernia repair has fluid volume excess and is at risk for left-sided heart failure
Which of the following signs and symptoms indicates left-sided heart failure?
A) Jugular vein distention
B) Right upper quadrant pain
C) Bibasilar fine crackles
D) Dependent edema
Ans: C
Feedback: Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload. Jugular vein distention, right upper-quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
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A nurse is conducting a mental status assessment for a client admitted to a health care facility. Under which conditions would the nurse need to collect the greatest proportion of objective assessment data?
A) When the client has visible wounds B) When the client pays attention to the nurse's instruction C) When the client has taken an overdose of drugs D) When the client has an active infection
The mother of a 4-year-old tells the nurse that her son spends his day in constant motion. The
mother tries to get him interested in playing with his toys, but he is easily distracted and does not seem to listen. He talks appropriately but excessively. He gets out of bed in the morning before his mother. She reports that one morning he broke the screen on the TV. She enrolled him in preschool, but the teacher was unable to handle him. The suggestion was made that he should be evaluated at the mental health clinic. The nurse can assess that the child's problem is most consistent with the DSM-IV-TR criteria for a. pervasive developmental disorder. b. mental retardation. c. oppositional defiant disorder. d. attention deficit hyperactivity disorder.
An older client receiving warfarin, with alternating doses of 2.5 mg and 5 mg, has an INR of 6.3. What are the immediate nursing interventions for this client? Select all that apply.
1. Prepare to begin a heparin infusion. 2. Administer vitamin K as prescribed. 3. Evaluate liver function tests. 4. Withhold the next warfarin dose. 5. Determine if there is a recent type and crossmatch
A nurse is working at a high school when a young woman comes down to the nursing office concerned about her boyfriend whom she states is making suicidal comments. How does the nurse proceed?
A. Counsel the young woman about relationship issues. B. Call the young woman's parents about her concerns. C. Inform the school psychologist immediately and notify the boyfriend's parents. D. Call the young man down to the nurse's office for a mental health evaluation.