While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?
Jugular vein atherosclerosis
Increased fluid volume
Decreased fluid volume
Incompetent jugular vein valves
The Correct Answer is B
Jugular venous distention (JVD) is a clinical sign that indicates increased fluid volume or fluid overload in the cardiovascular system. When the head of the client's bed is elevated at 45 degrees, the jugular veins should normally be flat or slightly distended. However, if the jugular veins appear engorged and bulging, it suggests that there is an increased amount of blood returning to the right side of the heart and is unable to be efficiently pumped forward, leading to jugular venous distention.
JVD is commonly seen in conditions such as heart failure, where the heart's ability to pump blood efficiently is compromised, leading to fluid accumulation in the veins and eventually causing jugular venous distention.
Option A, jugular vein atherosclerosis, is not a common cause of JVD. Atherosclerosis refers to the build-up of plaque within arteries, not veins.
Option C, decreased fluid volume, would lead to dehydration and decreased venous filling, which would not cause jugular venous distention. It would lead to flat or sunken jugular veins.
Option D, incompetent jugular vein valves, would not cause jugular venous distention with the head of the bed elevated. Incompetent valves may lead to venous reflux or backward flow of blood, but it would not lead to the distention of the jugular veins in this position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This statement indicates effective learning because serum cardiac markers are indeed proteins that are released from necrotic (damaged) heart muscle cells when there is myocardial injury, such as in acute coronary syndrome (ACS). These markers are measured in blood tests and help in the diagnosis and assessment of ACS, particularly myocardial infarction (heart attack).
Option A is incorrect because a nitroprusside stress echocardiogram is not used for acute pericarditis. It is a diagnostic test used for evaluating coronary artery disease and ischemia.
Option B is incorrect because a pathologic Q wave is not always present in the electrocardiogram (ECG) of patients with unstable angina. It is a characteristic finding in the ECG of patients with a previous myocardial infarction (heart attack) but may not be present in unstable angina.
Option D is incorrect because coronary angiography is not the only way to confirm the diagnosis of unstable angina. Unstable angina is primarily diagnosed based on the clinical presentation, symptoms, and changes in the ECG. Coronary angiography is an invasive procedure used to visualize the coronary arteries directly and is typically reserved for cases where further assessment and intervention are needed, such as in cases of suspected coronary artery disease.
Correct Answer is B
Explanation
The client presenting to the emergency department with a severe headache, nausea, and significantly elevated blood pressure (BP) of 238/118 mm Hg indicates a hypertensive crisis, which is a severe and potentially life-threatening condition. In such cases, the nurse's priority is to assess for potential triggers or exacerbating factors for the hypertensive crisis.
Option B, "Have there been recent stressful events in your life?" is the most relevant question to follow up on the findings. Stress is a known trigger for acute elevations in blood pressure, and severe stress can lead to a hypertensive crisis in individuals with a history of hypertension. Identifying recent stressful events may help the nurse understand potential contributing factors to the client's current condition and guide the management plan.
Option A, "Have you recently taken any antihistamines?" is not the most relevant question in this situation. Antihistamines are not typically associated with causing a hypertensive crisis. While certain medications and substances can interact with antihypertensive medications, causing an increase in BP, the severity of the client's symptoms and the extremely high BP reading suggest that a more immediate concern needs to be addressed.
Option C, "Have you consistently taken your medications?" is important for assessing medication adherence, but it may not directly explain the acute hypertensive crisis. The client's current symptoms and BP reading require more immediate investigation into potential triggers.
Option D, "Did you take any aspirin (or Tylenol) today?" is relevant to assess whether the client has recently taken any over-the-counter medications that could potentially interact with their prescribed antihypertensive drugs. However, it is not the most critical question to address the hypertensive crisis and the severity of the client's symptoms.
Given the severity of the client's presentation, the nurse should also promptly initiate appropriate interventions to address the hypertensive crisis, such as administering antihypertensive medications as prescribed, monitoring vital signs frequently, and notifying the healthcare provider for further evaluation and management.
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