A nurse is caring for a 46-year-old male client in the emergency department who is experiencing difficulty breathing that has worsened over the last 24 hours.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Positive Homan’s sign bilaterally indicates deep vein thrombosis (DVT) but does not directly correlate with swelling.
Choice B rationale
2+ pitting edema of ankles bilaterally is a direct indication of swelling and supports the client’s statement about their feet swelling all the time.
Choice C rationale
Pedal pulses weak and thready indicate poor arterial circulation but do not directly confirm swelling.
Choice D rationale
Capillary refill in both feet greater than 3 seconds indicates poor peripheral perfusion but does not directly correlate with swelling.

A. Inspection of head and neck is observed in a straight alignment without lateral curves. B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. C. Palpation of the spinous processes and surrounding muscles are non-tender. D. Observation of cervical range of motion reveals flexion and extension is 25 degrees.

Correct Answer is D

Explanation

A. Inspection of head and neck is observed in a straight alignment without lateral curves: A straight, well-aligned cervical spine is normal and does not indicate a need for further assessment of lifestyle habits.

B. Evaluation of cranial nerve XI (spinal accessory nerve) reveals flexion is maintained against full resistance:This indicates normal strength of the sternocleidomastoid and trapezius muscles, meaning there is no concern related to lifestyle habits.

C. Palpation of the spinous processes and surrounding muscles are non-tender: The absence of tenderness suggests that there is no acute inflammation, injury, or muscle strain, making further lifestyle inquiries unnecessary.

D. Observation of cervical range of motion reveals flexion and extension is 25 degrees:Normal cervical flexion and extension range from 45 to 90 degrees. A limitation to only 25 degrees suggests restricted mobility, which could be due to poor posture, occupational strain, prolonged screen time, or underlying musculoskeletal conditions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding supports the client statement, “My feet swell all the time?”

Correct Answer is B

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is D

Explanation

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

The nurse examines a client’s right great toe. The joint is red, edematous, and very painful with limited range of motion. The client’s serum uric acid levels are elevated. Which action should the nurse tell the client to make?