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?"

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Performing a 12-lead ECG: An ECG is the most definitive and immediate tool to determine if chest pain is cardiac in origin, as it can detect ischemic changes, arrhythmias, or other cardiac abnormalities.

B. Administering NTG to see if the pain goes away: While nitroglycerin (NTG) may relieve ischemic chest pain, it is not definitive for diagnosing the pain's origin and should not be the first step without further assessment.

C. Gathering a complete medical history: Although a medical history is important, it will not immediately determine if the pain is cardiac in origin.

D. Asking the patient if performing a Valsalva maneuver reduces the pain: The Valsalva maneuver is not a reliable method to differentiate cardiac from non-cardiac chest pain and could potentially worsen certain conditions.

A. Pallor and/or cyanosis of extremities B. Orthopnea, peripheral edema, crackles C. Dizziness, syncope. palpitations D. PAWP of 12 and CVP of 6

Correct Answer is B

Explanation

A. Pallor and/or cyanosis of extremities: While pallor and cyanosis can indicate severe heart failure, they are not early signs. These symptoms usually appear later in the disease process.

B. Orthopnea, peripheral edema, crackles: These are early signs of heart failure indicating fluid overload due to decreased cardiac output. Orthopnea is difficulty breathing when lying flat, peripheral edema is swelling in the limbs, and crackles indicate fluid in the lungs.

C. Dizziness, syncope, palpitations:These symptoms can occur in heart failure but are not specific to fluid overload; they are more indicative of decreased cardiac output and possible arrhythmias.

D. PAWP of 12 and CVP of 6: These values are within normal limits. PAWP (Pulmonary Artery Wedge Pressure) and CVP (Central Venous Pressure) would be elevated in fluid overload.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin?

Correct Answer is A

Explanation

The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure?

Correct Answer is B

Explanation

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