The nurse is assessing a client with a diagnosis of mitral stenosis. Which piece of assessment data indicates that the disease is worsening?

Jugular vein distention and +3 peripheral edema

Increase in systolic blood pressure 10 mmHg above cents norm

Complaints of epigastric pain after eating a large meal

Complaints of dyspnea while completing ADLs

Answer and Explanation

The Correct Answer is A

A. Jugular vein distention and +3 peripheral edema are signs of right-sided heart failure, which can result from worsening mitral stenosis. As the mitral valve becomes more narrowed, it leads to increased pressure in the left atrium and eventually backs up into the lungs and right side of the heart, causing fluid retention.
B. An increase in systolic blood pressure by 10 mmHg does not directly indicate worsening mitral stenosis. Blood pressure changes can occur for various reasons but are not as specific as signs of heart failure in this context.
C. Complaints of epigastric pain after eating a large meal are typically related to gastrointestinal issues rather than directly indicating worsening mitral stenosis.
D. Complaints of dyspnea while completing activities of daily living (ADLs) can be a sign of worsening mitral stenosis, but the additional signs of jugular vein distention and edema are more definitive indicators of worsening disease.

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Correct Answer is C

Explanation

A. The subdivision of pancreatic tumors into endocrine versus exocrine reflects their cell of origin (islet cells versus ductal cells) rather than conveying information about how the cancer behaves in situ or its propensity for local invasion and metastasis

B. Unlike some other cancers (e.g., colorectal cancer), pancreatic cancer does not typically develop from polyps. Most cases of pancreatic cancer develop from the pancreatic ductal cells (the cells lining the ducts of the pancreas), and the disease is typically aggressive and diagnosed at a later stage.

C. Because the pancreas lies deep in the retroperitoneum directly adjacent to major vessels like the superior mesenteric artery and portal vein, tumors often extend into these structures early, contributing to the high rate of advanced disease at diagnosis

D. Pancreatic cancer is not distinguished based on layers. Instead, it is generally categorized based on the type of cells it affects (e.g., ductal cells in exocrine pancreatic cancer). The staging of pancreatic cancer is based on factors like tumor size, lymph node involvement, and metastasis, rather than the layers of the pancreas.

A. Pain level B. Urinary output C. Tactile fremitus D. Chest tube drainage

Correct Answer is D

Explanation

A. Pain management is an important aspect of postoperative care, particularly after a thoracotomy and lobectomy. However, it is not the highest priority compared to monitoring for potential complications, such as bleeding or respiratory distress, which are more immediately life-threatening.

B. Urinary output is an important indicator of renal function and hydration status. However, in the immediate postoperative period following thoracotomy and lobectomy, monitoring chest tube drainage for excessive bleeding or signs of a complication, like pneumothorax, is more critical for the patient's immediate stability than monitoring urinary output.

C. Tactile fremitus refers to the palpable vibration on the chest wall when a patient speaks. It is helpful in assessing lung consolidation or other lung issues, but it is not as critical to assess immediately in the postoperative phase as monitoring for complications related to chest tube drainage, which is directly linked to the patient's respiratory and hemodynamic status.

D. After a thoracotomy and lobectomy, monitoring chest tube drainage is of utmost importance. The nurse should assess the color, amount, and consistency of drainage to detect any excessive bleeding or signs of a complication like a pneumothorax or hemothorax. Significant drainage (especially >100 mL/hr for several hours) could indicate bleeding, which is a critical postoperative complication that requires immediate intervention.

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The nurse is assessing a client with a diagnosis of mitral stenosis. Which piece of assessment data indicates that the disease is worsening?

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