A nurse observes the following during the physical exam. How will the nurse document this finding?

Grey-Turner Sign

Steatorrhea

Asterixis

Cullen's Sign

Answer and Explanation

The Correct Answer is D

A. Grey-Turner Sign: Grey-Turner Sign refers to bruising along the flanks, often associated with retroperitoneal hemorrhage or acute pancreatitis.

B. Steatorrhea: Steatorrhea refers to fatty stools that are pale, bulky, and foul-smelling, indicating malabsorption, not a physical exam finding on the skin.

C. Asterixis: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, seen in hepatic encephalopathy, not a skin finding.

D. Cullen's Sign: Cullen's Sign is bruising around the umbilicus, indicating intra-abdominal bleeding, often seen in conditions such as acute pancreatitis or ruptured ectopic pregnancy.

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Correct Answer is B

Explanation

A. "Now you can eat whatever you want": This is incorrect and dangerous advice. Lifestyle changes, including diet, are crucial for preventing the progression of coronary artery disease even after a CABG.

B. "A CABG is not a cure - It may improve your quality of life": This response educates the patient that while CABG can relieve symptoms and improve quality of life, it does not cure the underlying disease. Continued management and lifestyle changes are essential.

C. "I am happy for you": While this might express empathy, it does not provide the necessary education or correction of the patient’s misconception about CABG.

D. "A CABG is not a cure - but now you can stop taking your medications": This is incorrect. Most patients will need to continue taking medications such as antiplatelets, statins, and antihypertensives to manage their condition post-CABG.

A. An increase in O2 saturation to greater than 90% B. The onset of atrial fibrillation C. Louder S, and S2 heart sounds D. A decrease in heart rate to 66 bpm

Correct Answer is B

Explanation

A. An increase in O2 saturation to greater than 90%: An increase in oxygen saturation is typically a positive sign and does not indicate worsening heart failure.

B. The onset of atrial fibrillation: The development of atrial fibrillation (AFib) in a patient with heart failure is a sign of worsening heart failure, as it indicates increased atrial pressure and the potential for further hemodynamic compromise.

C. Louder S1 and S2 heart sounds: Louder heart sounds do not specifically indicate worsening heart failure. They may vary based on other factors such as body habitus or the position of the patient.

D. A decrease in heart rate to 66 bpm: A heart rate of 66 bpm is within the normal range and does not suggest worsening heart failure.

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A nurse observes the following during the physical exam. How will the nurse document this finding?

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