A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit?

Bradycardia, palpitations, confusion, truncal rash.

Severe respiratory distress, jugular venous distention, chest pain.

Low blood pressure and tachycardia.

Reduced cardiac output, increased systemic vascular resistance, moist cough.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Bradycardia, palpitations, confusion, and truncal rash are not typically associated with septic shock. Septic shock is a severe infection that occurs when bacteria enter the bloodstream. It can cause organs to fail and can lead to death.
Choice B rationale
Severe respiratory distress, jugular venous distention, and chest pain are more commonly associated with conditions like heart failure or pulmonary embolism, not septic shock.
Choice C rationale
Low blood pressure and tachycardia are common symptoms of septic shock. This happens because the body’s response to the infection causes blood vessels to dilate, which can lower blood pressure. The heart rate often increases (tachycardia) in an attempt to maintain blood flow to the organs.
Choice D rationale
Reduced cardiac output, increased systemic vascular resistance, and a moist cough are not typical symptoms of septic shock. These symptoms are more commonly associated with conditions like heart failure.

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Correct Answer is B

Explanation

Choice A rationale
Administering Lasix (a diuretic) would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. Lasix is used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine.
Choice B rationale
The most important nursing intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin would be to increase myocardial oxygenation. This can be achieved by administering supplemental oxygen and ensuring the patient is in a position that maximizes respiratory efficiency (such as semi-Fowler’s position). This intervention addresses the immediate life-threatening situation of myocardial ischemia.
Choice C rationale
Obtaining one hour of echocardiogram readings would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. While an echocardiogram can provide valuable information about the structure and function of the heart, it is not the first step in managing acute chest pain.
Choice D rationale
Decreasing the patient’s anxiety is an important aspect of care, but it is not the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. The priority is to address the physical cause of the chest pain.

A. Cyanosis and hypoxia B. High-pitched cry and dyspnea C. Leg pain and twitching D. Epistaxis and anemia

Correct Answer is A

Explanation

Choice A rationale
Tetralogy of Fallot is a congenital heart condition that presents with a combination of four defects in the structure of the heart. The most common symptoms in a newborn with this condition include cyanosis (bluish color of the skin due to reduced oxygen in the blood) and hypoxia (low levels of oxygen in the body)34567.
Choice B rationale
While a high-pitched cry can be a sign of distress in a newborn, it is not specifically associated with tetralogy of Fallot. Dyspnea (difficulty breathing) can occur in severe cases, but it is not one of the primary symptoms of this condition.
Choice C rationale
Leg pain and twitching are not typical symptoms of tetralogy of Fallot. These symptoms could be indicative of other conditions, but they are not associated with this specific congenital heart defect.
Choice D rationale
Epistaxis (nosebleeds) and anemia are not typical symptoms of tetralogy of Fallot. While these conditions can occur in children for various reasons, they are not directly related to this specific congenital heart defect.

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A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A newborn child has been diagnosed with tetralogy of Fallot. What symptoms would the nurse expect to observe in this child?

Correct Answer is A

Explanation

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