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 ["A","C","D"]
Explanation
A. Auscultate the chest for bilateral breath sounds: Auscultating the chest immediately after intubation ensures that the endotracheal tube is correctly placed in the trachea and not in the esophagus or a bronchus.
B. Assess the patient's blood glucose: Blood glucose monitoring is not immediately necessary following intubation.
C. Determine the CO2 level: Measuring end-tidal CO2 (ETCO2) is crucial to confirm that the tube is in the trachea and that ventilation is occurring effectively.
D. Obtain a stat PCXR (Portable Chest X-ray): A chest X-ray is obtained to confirm the correct placement of the endotracheal tube, ideally 2-3 cm above the carina.
Correct Answer is C
Explanation
A. "A complex measurement that should only be discussed with your health care provider": This response is dismissive and does not provide the patient with valuable information or education.
B. "A measurement that should always be 120/80 unless complications are present": While 120/80 mmHg is a common target, blood pressure varies based on individual health and other factors.
C. "A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against": This response accurately explains that blood pressure is the force of blood against the walls of the arteries and is influenced by cardiac output and vascular resistance.
D. "The amount of pressure exerted on your veins by the blood": Blood pressure refers to the pressure within the arteries, not veins.
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