A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?
"To the best of your knowledge, are your immunizations up to date?"
"Have you ever worked in an occupation where you might have been exposed to toxins?"
"How many alcoholic drinks do you typically consume in a week?"
"Has anyone in your family ever experienced symptoms similar to yours?"
The Correct Answer is C
A. "To the best of your knowledge, are your immunizations up to date?" Immunization status is important but is not directly related to the symptoms of jaundice and increased abdominal girth.
B. "Have you ever worked in an occupation where you might have been exposed to toxins?" While toxin exposure could contribute to liver disease, it is less likely the immediate cause compared to alcohol consumption.
C. "How many alcoholic drinks do you typically consume in a week?" Alcohol consumption is a major risk factor for liver disease, which can lead to jaundice and ascites (increased abdominal girth).
D. "Has anyone in your family ever experienced symptoms similar to yours?" Family history is less relevant for acute symptoms of jaundice and abdominal girth, which are more likely related to lifestyle factors like alcohol use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ask a family member to interpret what the client is trying to communicate: While family members can sometimes help, the nurse should directly facilitate communication with the client using appropriate tools.
B. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk: Weaning off a ventilator should only be done based on medical stability, not solely for communication purposes.
C. Ask the client to write, use a picture board, or spell words with an alphabet board: These tools can help non-verbal clients on mechanical ventilation express themselves and reduce frustration.
D. Assure the client that everything will be all right and that he shouldn't become upset: This response is dismissive and does not address the client's need to communicate.
Correct Answer is A
Explanation
A. Hypertension: This is not a cause of high-output heart failure. Hypertension typically leads to low-output heart failure due to increased afterload, which causes the heart to work harder.
B. Severe anemia: Severe anemia causes high-output heart failure because the body compensates for the decreased oxygen-carrying capacity by increasing cardiac output.
C. Sepsis: Sepsis can lead to high-output heart failure as the body attempts to maintain perfusion in the face of widespread vasodilation.
D. Hyperthyroidism: Hyperthyroidism increases metabolic demands, which can cause high-output heart failure as the heart attempts to meet the increased needs.
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