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. Near-drowning: This is a direct cause of ARDS. Inhalation of water can lead to pulmonary edema, which triggers ARDS.
B. Aspiration: Aspiration of gastric contents can directly injure the lungs and is a well-known cause of ARDS.
C. Pancreatitis: Pancreatitis is associated with ARDS, but it is an indirect cause, not a direct one. The inflammatory response from pancreatitis can lead to ARDS, but it is not due to direct lung injury.
D. Toxic inhalation: Inhaling toxic substances can cause direct damage to the alveoli and lead to ARDS.
Correct Answer is B
Explanation
A. Respiratory acidosis: Respiratory acidosis would present with a low pH (below 7.35) and a high PaCO2 (above 45 mmHg).
B. Respiratory alkalosis: This ABG shows a high pH (7.51), low PaCO2 (32 mmHg), and normal HCO3- (26 mEq/L), indicating respiratory alkalosis, typically due to hyperventilation.
C. Metabolic acidosis: Metabolic acidosis would present with a low pH and low HCO3-, but in this case, the HCO3- is normal.
D. Metabolic alkalosis: Metabolic alkalosis would show a high pH and high HCO3-, but the HCO3- in this ABG is normal.
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