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Exhibits

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Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

Client reports tightness in chest that radiates to left arm

States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast

Client is diaphoretic and short of breath

Heart rate irregular and tachycardic

I had scrambled eggs and bacon like I do every morning

Lungs clear to auscultation in all lobes

+1 pedal pulses

Capillary refill less than 2 seconds

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Client reports tightness in chest that radiates to left arm: Chest tightness that radiates to the left arm is a classic symptom of myocardial ischemia or infarction (heart attack). This symptom is concerning because it suggests potential heart muscle damage or decreased blood flow to the heart.

States pain as 7 on a scale of 0 to 10: The client rates their chest pain as 7 out of 10. This indicates significant discomfort and suggests that the chest tightness is causing substantial pain. Pain severity is an important indicator in assessing the severity of the cardiac event.

Started to feel nauseous after breakfast: Nausea can be a symptom associated with myocardial ischemia or infarction, particularly when it occurs after physical exertion or a meal. It can be caused by decreased blood flow to the gastrointestinal tract due to compromised cardiac function.

Client is diaphoretic and short of breath: Diaphoresis (excessive sweating) and shortness of breath are additional symptoms that commonly accompany acute myocardial infarction. Diaphoresis occurs due to sympathetic nervous system activation, while shortness of breath can result from decreased cardiac output or pulmonary congestion.

Heart rate irregular and tachycardic: An irregular and tachycardic (rapid) heart rate is abnormal and suggests cardiac dysrhythmia, which can occur in response to myocardial ischemia or infarction. It reflects the heart's attempt to compensate for reduced oxygen delivery to the body.

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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.

A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.

C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.

D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning

A. Bradycardia B. Photophobia C. Petechiae on the chest D. Intermittent headache

Correct Answer is B

Explanation

B. Photophobia, or sensitivity to light, is a common symptom in clients with meningitis. It occurs due to irritation of the meninges and the optic nerve by the inflammatory process. Clients may avoid bright lights and prefer dimly lit environments to reduce discomfort.

A Bradycardia (slow heart rate) is not typically associated with meningitis. In fact, many clients with meningitis may present with tachycardia (fast heart rate) due to fever, dehydration, and systemic inflammation. Therefore, bradycardia is not an expected finding in meningitis.

C. Petechiae (small red or purple spots) on the chest can occur in bacterial meningitis, particularly in cases caused by Neisseria meningitidis. These petechiae are often seen in clusters and can indicate disseminated intravascular coagulation (DIC), a serious complication associated with meningococcal infection. However, they are less specific

D. Headache is a hallmark symptom of meningitis, typically described as severe and persistent. It is often accompanied by other symptoms such as fever, neck stiffness (nuchal rigidity), photophobia, and altered mental status. Headache in meningitis is usually continuous rather than intermittent.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include?