Which client should receive the pictured examination first?

a client with nausea, vomiting, and abdominal pain

a client with chest tightness and heartburn

a client with facial drooping and left-sided weakness

a client with fatigue, fever, and productive cough

Answer and Explanation

The Correct Answer is C

Choice A rationale: A client with nausea, vomiting, and abdominal pain may have gastroenteritis, food poisoning, or appendicitis, which are not directly related to the eyes.

Choice B rationale: A client with chest tightness and heartburn may have gastroesophageal reflux disease (GERD), angina, or myocardial infarction (MI), which are also not associated with the eyes.

Choice C rationale: A client with facial drooping and left-sided weakness may have a stroke, which is a medical emergency that requires immediate attention. An eye examination can help detect signs of stroke, such as pupil asymmetry, visual field defects, or eye movement abnormalities. A stroke can cause permanent brain damage or death if not treated promptly.

Choice D rationale: A client with fatigue, fever, and productive cough may have a respiratory infection, such as pneumonia or tuberculosis, which are unlikely to affect the eyes unless there is a systemic complication.

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Correct Answer is B

Explanation

Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.

Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.

Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.

Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.

A. Keeping the room well-lit at all time B. Encouraging frequent ambulation and exercise C. Providing a high-calorie and high protein diet D. Placing extra blankets over the client

Correct Answer is C

Explanation

Choice A rationale: Clients with Graves' disease may have increased sensitivity to light due to ocular manifestations like photophobia, so keeping the room well-lit may can cause eye irritation.

Choice B rationale: Encouraging frequent ambulation and exercise may worsen the symptoms of hyperthyroidism, such as tachycardia, palpitations, and tremors.

Choice C rationale: This is because clients with Graves' disease have an increased

metabolic rate and may experience weight loss, muscle wasting, and fatigue. A high- calorie and high protein diet can help prevent these complications and provide adequate nutrition for the client.

Choice D rationale: Placing extra blankets over the client may increase the body temperature and cause heat intolerance, which is another common symptom of Graves' disease.

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Which client should receive the pictured examination first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease. Which of the following interventions does the nurse include in the plan of care?

Correct Answer is C

Explanation

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