The nurse cares for a client with diabetes mellitus and congestive heart failure.
Which two (2) client findings in the history and physical are most concerning? Select all that apply
Oral temperature
Thready pulse
Reports of thirst
Recently lost his job
Medical history of CHF
Correct Answer : B,D
Choice A rationale: While the temperature is important in assessing health, it isn't the most concerning finding in this scenario compared to others.
Choice B rationale: A thready pulse (a weak, barely palpable pulse) could indicate a critical drop in blood pressure and cardiac output, which is a significant concern.
Choice C rationale: While indicating a possible issue with hydration, it's not as immediately concerning as other findings in this context.
Choice D rationale: Recently lost his job - While this has social and economic implications, it's not an immediate physiological concern in this clinical scenario.
Choice E rationale: While significant in his overall health, it's not a direct finding from the current assessment that immediately raises concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Arterial blood gas (ABG) findings provide direct information about oxygenation and acid-base balance in the blood, which can indicate hypoxemia and metabolic acidosis.
Choice B rationale: Oxygen saturation level provides information about oxygen saturation in the blood but doesn't give a complete assessment of acid-base balance or other gases in the blood.
Choice C rationale: White blood cell differential assesses different types of white blood cells and is not directly related to evaluating hypoxemia or metabolic acidosis.
Choice D rationale: Red blood cells (RBCs) and hemoglobin count findings are important but do not directly assess hypoxemia or metabolic acidosis.
Correct Answer is D
Explanation
Choice A rationale: Expressive aphasia is a type of non-fluent aphasia that affects the
ability to produce language. It is caused by damage to the anterior part of the left frontal lobe, which is responsible for motor planning and execution of speech. Patients with expressive aphasia can understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.
Choice B rationale: this is another term for expressive aphasia. The patient can
understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.
Choice C rationale: Global aphasia is a severe form of aphasia that affects both
comprehension and production of language. It is caused by extensive damage to the left hemisphere of the brain, which is dominant for language functions in most people.
Patients with global aphasia have little or no ability to speak, write, read, or understand language.
Choice D rationale: Wernicke's aphasia is a type of receptive aphasia that affects the
comprehension and production of language. It is caused by damage to the posterior part of the left temporal lobe, which is responsible for processing auditory and visual
information. Patients with Wernicke's aphasia can speak fluently but nonsensically, using words that are irrelevant, invented, or distorted. They also have difficulty understanding spoken or written language and following commands.
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