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 C
Explanation
Choice A rationale: BSE will not reduce the risk of dying from breast cancer, but it may help you detect breast cancer earlier, when it is more treatable.
Choice B rationale: BSE should be done once a month, preferably at the same time each month. For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.
Choice C rationale: For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.
Choice D rationale: Annual mammograms are recommended for women aged 40 and older, or earlier if they have a high risk of breast cancer and not all women. Women aged less than 30 years should undergo breast ultrasound instead.
Correct Answer is D
Explanation
Choice A rationale: These are symptoms of advance renal failure. Stomatitis and diarrhea are signs of uremia, which is the accumulation of waste products in the blood.
Choice B rationale: Dyspnea and anuria are signs of fluid overload and kidney shutdown and indicate advanced renal failure.
Choice C rationale: Confusion and vomiting are signs of acidosis and electrolyte disturbances and occur in advanced stages of renal failure.
Choice D rationale: One of the early symptoms of renal insufficiency is nocturia, which is the need to urinate frequently at night. This occurs because the kidneys are unable to concentrate urine during the day and produce more urine at night. Another early symptom is oliguria, which is the production of less than 400 mL of urine per day. This occurs because the kidneys are unable to excrete enough urine to maintain fluid balance.
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