A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?

Sepsis.

Hypovolemic shock.

Myocardial infarction.

Pulmonary embolism.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Sepsis is a systemic inflammatory response to infection, often characterized by fever (temperature of 38°C or higher) and tachycardia (heart rate of 120 beats per minute or higher). These symptoms indicate the body’s response to a severe infection.
Choice B rationale
Hypovolemic shock is caused by significant fluid loss, leading to decreased blood volume and perfusion. It typically presents with hypotension and tachycardia, but not necessarily fever.
Choice C rationale
Myocardial infarction (heart attack) is characterized by chest pain, shortness of breath, and other symptoms, but fever and tachycardia are not primary indicators.
Choice D rationale
Pulmonary embolism involves a blockage in the pulmonary arteries, leading to symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, but not typically fever.

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Correct Answer is A

Explanation

Choice A rationale
Hypersplenism is a condition often associated with cirrhosis, where the spleen becomes overactive. This leads to the destruction of blood cells, causing anemia (low red blood cells), leukopenia (low white blood cells), and thrombocytopenia (low platelets)1.
Choice B rationale
Peptic ulcer disease primarily affects the stomach and duodenum, leading to ulcers and bleeding. It does not typically cause anemia, leukopenia, and thrombocytopenia in the context of cirrhosis.
Choice C rationale
Cholecystitis is the inflammation of the gallbladder, usually due to gallstones. It does not cause the blood cell abnormalities seen in cirrhosis.
Choice D rationale
Esophageal varices are swollen veins in the esophagus that develop due to portal hypertension in cirrhosis. While they can cause bleeding, they do not directly cause anemia, leukopenia, and thrombocytopenia.

A. The client reports increased shortness of breath. B. The client has a temperature of 37°C (98.6°F). C. The client has a blood pressure of 120/80 mmHg. D. The client reports occasional dizziness.

Correct Answer is A

Explanation

Choice A rationale
Increased shortness of breath is a key symptom of worsening congestive heart failure (CHF). It indicates that the heart is not effectively pumping blood, leading to fluid buildup in the lungs and increased respiratory effort.
Choice B rationale
A temperature of 37°C (98.6°F) is within the normal range and does not indicate worsening CHF. Monitoring the patient’s temperature is important, but it is not a sign of CHF exacerbation.
Choice C rationale
A blood pressure of 120/80 mmHg is within the normal range and does not indicate worsening CHF. Blood pressure should be monitored, but this reading does not suggest an acute issue.
Choice D rationale
Occasional dizziness can be a symptom of many conditions, including CHF, but it is not as specific or critical as increased shortness of breath. It should be monitored, but it does not indicate an immediate worsening of CHF.

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A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?

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Naxlex Comprehensive Predictor Exams

A client with a long history of cirrhosis has anemia, leukopenia, and thrombocytopenia. In the context of cirrhosis, these three conditions are most likely caused by:

Correct Answer is A

Explanation

A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?

Correct Answer is A

Explanation

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