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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice B rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice C rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice D rationale: Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.
Correct Answer is C
Explanation
Choice A rationale: This is a general description of an imaging test, such as an X-ray, ultrasound, or MRI, which can show the structure of the organs but not the mucosal lining.
Choice B rationale: This is a general description of a blood test, which can show signs of infection, inflammation, or anemia, but not the cause of these problems.
Choice C rationale: This exam is called a colonoscopy, which involves inserting a flexible tube with a camera and light into the anus and advancing it through the colon. A colonoscopy can reveal signs of inflammation, ulcers, bleeding, or narrowing of the intestinal wall that are characteristic of Crohn's disease. A biopsy can also be taken during the procedure to confirm the diagnosis.
Choice D rationale: This is a general description of a urine test, which can show signs of kidney problems, urinary tract infections, or dehydration, but not Crohn's disease.
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