A nurse is caring for a client who has been admitted to the medical surgical unit.
Edema of the extremities
Jugular vein distention
Tachypnea
Ascites
Pink frothy sputum
Atelectasis
Correct Answer : A,B,C,E
A. Edema of the extremities
Fluid accumulation due to poor cardiac output contributes to peripheral edema.
B. Jugular vein distention
Reflects elevated central venous pressure from fluid overload.
C. Tachypnea
Increased respiratory rate is a compensatory mechanism for impaired oxygen exchange.
D. Ascites
Associated with liver disease or right-sided heart failure, not specifically pulmonary edema.
E. Pink frothy sputum
Classic sign of pulmonary edema due to fluid in the alveoli.
F. Atelectasis
Can occur in respiratory illness but is not a hallmark sign of pulmonary edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Edema of the extremities
Fluid accumulation due to poor cardiac output contributes to peripheral edema.
B. Jugular vein distention
Reflects elevated central venous pressure from fluid overload.
C. Tachypnea
Increased respiratory rate is a compensatory mechanism for impaired oxygen exchange.
D. Ascites
Associated with liver disease or right-sided heart failure, not specifically pulmonary edema.
E. Pink frothy sputum
Classic sign of pulmonary edema due to fluid in the alveoli.
F. Atelectasis
Can occur in respiratory illness but is not a hallmark sign of pulmonary edema.
Correct Answer is B
Explanation
A. "You would like more information..."
This doesn't address the emotional content of the client’s statement.
B. "You feel like you have no remaining options..."
This is therapeutic. It reflects the client’s feelings and encourages expression.
C. "If you do not like your medications..."
Redirects the conversation instead of acknowledging hopelessness.
D. "Would you like to speak to a therapist..."
While appropriate later, the immediate need is empathetic listening and validation.
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