A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?
Elevated blood pressure.
Rapid, irregular heart rate.
Swollen feet and ankles.
Blood-tinged sputum.
The Correct Answer is D
Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.
Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.
Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.
Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Discussing symptomless partners may give false reassurance, as herpes can be transmitted even when symptoms are not present.
Choice B reason: Notifying sexual partners is crucial for public health and the prevention of further transmission of STIs.
Choice C reason: While it's true that STIs are reported, this does not provide the client with actionable advice for their situation.
Choice D reason: Most contraceptives do not protect against STIs like genital herpes, which is spread by skin-to-skin contact.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Choice A reason: No understanding.
While lifestyle changes can significantly reduce the risk of developing type 2 diabetes, they do not guarantee prevention. The client’s family history and current prediabetic fasting blood glucose level (122 mg/dL) indicate an increased risk. It’s important to understand that while risk can be minimized, it cannot be completely eliminated12.
Choice B reason:
People with diabetes or prediabetes can still consume sugar, but it should be in moderation and as part of a balanced diet. The DASH diet discussed with the client emphasizes portion control and a reduction in sugar intake, not complete elimination.
Choice C reason: No understanding
A single fasting blood glucose measurement below 100 mg/dL does not mean the client can revert to previous eating habits. Ongoing maintenance of a healthy diet and lifestyle is necessary to manage blood glucose levels and reduce the risk of diabetes.
Choice D reason: Understanding.
Lifestyle changes such as adopting the DASH diet and increasing physical activity can help manage weight, improve cholesterol levels, and lower the risk of chronic conditions like hypertension, cardiovascular disease, and type 2 diabetes.
Choice E reason: Understanding.
Increased thirst and urination are symptoms of high blood sugar levels. If the client experiences these symptoms, it would be prudent to check blood glucose levels to manage and monitor for diabetes.
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