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","D","F"]
Explanation
Choice A rationale: Altered consciousness is a hallmark feature of delirium, where individuals may experience fluctuations in awareness.
Choice B rationale: Delirium typically has an acute onset rather than symptoms developing over months to years.
Choice C rationale: Delirium often has a fluctuating course, rather than a consistent progressive decline.
Choice D rationale: Delirium can result from various factors including fluid/electrolyte imbalances or infections.
Choice E rationale: While these conditions might contribute to cognitive impairments, they are not typically associated with delirium.
Choice F rationale: Delirium can affect judgment, but it's not a defining feature.
Choice G rationale: While memory impairments can be seen in delirium, they're often accompanied by altered consciousness and fluctuations in awareness.
Correct Answer is A
Explanation
Choice A rationale: Propranolol, a beta-blocker used for high blood pressure and other cardiovascular conditions, is known to have potential side effects of sexual dysfunction, including erectile dysfunction (ED).
Choice B rationale: Ranitidine (Zantac) is an H2 blocker used for acid reflux and isn't typically associated with causing ED.
Choice C rationale: Atorvastatin (Lipitor), a statin used for high cholesterol, isn't commonly associated with causing ED.
Choice D rationale: Metformin (Glucophage), used for type 2 diabetes, is not typically linked to causing ED.
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