A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Encouraging the patient to take deep breaths and cough

Administering oxygen to maintain adequate oxygenation

Positioning the patient flat in bed to decrease discomfort

Providing the patient with a warm compress to relieve chest pain

Positive Tinel's sign

Answer and Explanation

The Correct Answer is B

A.   Encouraging the patient to take deep breaths and cough would not address the underlying cause of the symptoms, which may indicate a more serious condition.
B.   Administering oxygen to maintain adequate oxygenation is the most appropriate initial action, as the patient’s symptoms suggest a potentially life-threatening condition like a cardiac tamponade or pulmonary embolism.
C.   Positioning the patient flat in bed is not recommended, as it may exacerbate breathing difficulties and
the patient’s distress.
D.   A warm compress is unlikely to be beneficial in this acute situation and could delay appropriate intervention.

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Correct Answer is D

Explanation

A. Administering an anti-diarrheal medication as prescribed might help control the symptoms, but it is important to address the underlying cause of the diarrhea first, such as adjusting the feeding.
B. Increasing water flushes may help with hydration, but it does not specifically address the diarrhea caused by the enteral feeding. It's more important to manage the feeding itself.
C. Switching the feeding method to bolus feeding could increase the risk of aspiration and discomfort. Continuous feeding is generally safer and better tolerated in this context.
D. Decreasing the feeding rate and consulting the dietitian for a fiber-enriched formula is the most appropriate response. Adjusting the feeding rate can help reduce gastrointestinal upset, and a fiber- enriched formula can help firm up stools.

A. Paresthesia B. Nausea and vomiting C. Dysphagia D. Spasticity E. Vertigo

Correct Answer is ["A","C","D","E"]

Explanation

A. Paresthesia, or abnormal sensations such as tingling or numbness, is a common symptom in patients with multiple sclerosis due to nerve damage.
B. Nausea and vomiting are not typical symptoms of multiple sclerosis but may occur in specific cases due to other complications.
C. Dysphagia, or difficulty swallowing, can occur in multiple sclerosis as a result of nerve damage affecting the muscles involved in swallowing.
D. Spasticity, or muscle stiffness, is common in multiple sclerosis due to damage to the nerve pathways that control muscle movement.
E. Vertigo, or dizziness, is a frequent symptom of multiple sclerosis due to lesions in the brainstem affecting balance.

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A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient receiving continuous enteral feeding through a nasogastric tube. During the assessment, the nurse discovers that the patient is experiencing diarrhea. Which of the following actions should the nurse take to address this complication?

Correct Answer is D

Explanation

A nurse is assessing a client who has multiple sclerosis. Which of the following assessment findings should the nurse anticipate? (Select All that Apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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