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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Anorexia is a common symptom after surgery and may be due to the stress of surgery, anesthesia, or the body's adjustment to changes in digestion. While it requires monitoring, it is not an immediate concern unless it worsens or is accompanied by other signs of complications.
B. Mild to moderate pain is expected after surgery, especially following major procedures like gastric cancer surgery. Pain management is important, but it is not usually an immediate concern unless it is severe, unmanageable, or worsens suddenly.
C. Excessive sweating (diaphoresis) after surgery could indicate a serious complication, such as hypovolemic shock, infection, or a cardiovascular event. It is critical for the nurse to assess for other signs, such as low blood pressure, rapid heart rate, or fever, and take immediate action.
D. Nausea can occur after surgery and is a common side effect from anesthesia, pain medications, or the digestive system adjusting. While it requires management, it is typically not as urgent as diaphoresis, unless it is persistent or associated with other concerning symptoms like vomiting or dehydration.
Correct Answer is C
Explanation
A. While the liver is centrally located and plays a significant role in filtering blood, its location alone does not directly explain why it's a common site for metastasis.
B. Portal hypertension refers to increased pressure within the portal vein system, usually due to liver disease, not metastasis.
C. The liver has a dual blood supply from the portal vein and the hepatic artery, which makes it a key organ for filtering blood coming from the digestive tract. This provides a route for cancer cells from the gastrointestinal tract and other organs to travel to the liver, making it a common site for metastasis.
D. Tumor markers are substances that may be found in higher amounts in the blood or tissues of people with cancer. However, they do not directly explain why the liver is a common site for metastasis.
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