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 B
Explanation
A. Dark colored urine: Dark urine can be a sign of bilirubin buildup in the body due to liver dysfunction, commonly seen in cirrhosis.
B. Dark colored stool: This is not typically associated with cirrhosis. Dark stools can indicate gastrointestinal bleeding, but in cirrhosis, stools are more likely to be pale or clay-colored due to a lack of bile.
C. Jaundice: Jaundice occurs due to the liver's inability to process bilirubin, leading to yellowing of the skin and eyes.
D. Pruritus: Pruritus, or itching, is common in cirrhosis due to bile salt deposition in the skin.
E. Ascites: Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis due to portal hypertension and low albumin levels.
Correct Answer is B
Explanation
A. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.
B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).
C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.
D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.