An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

Fatigue.

Lower extremity edema.

Hepatomegaly.

Jugular vein distension.

Answer and Explanation

The Correct Answer is A

Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the systemic circulation. This leads to fatigue and exertional dyspnea.
B. Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.
C. Hepatomegaly is a typical finding in right ventricular dysfunction
D. Jugular vein dysfunction is a typical finding in right ventricular dysfunction.

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Correct Answer is C

Explanation

C. The client's symptoms of weakness and palpitations are suggestive of hypoglycemia, a common complication in individuals with diabetes, particularly those on glucose-lowering medications such as insulin or sulfonylureas. Excessive perspiration, also known as diaphoresis, is a classic symptom of hypoglycemia and indicates the body's response to low blood sugar levels.

A. Cold extremities can be a sign of poor peripheral circulation, which may occur in individuals with diabetes, particularly in advanced stages or in the presence of peripheral vascular disease. However, it is not as specific to the acute episode of hypoglycemia
B. Myalgia (muscle pain) in the wrists and hands is not a typical symptom of hypoglycemia.
D. Dark yellow urine may indicate dehydration, which can occur in individuals with poorly controlled diabetes or during episodes of hyperglycemia. While dehydration is a concern in diabetes management, it is not directly related to the acute episode of hypoglycemia.

A. Release the traction so the client can use a bedpan. B. Log roll the client and place adult disposable briefs beneath the client. C. Insert an indwelling urinary catheter preoperatively. D. Maintain traction while the client uses a urinal.

Correct Answer is D

Explanation

A. Releasing traction to use a bedpan may cause pain and discomfort to the client and risk exacerbating the fracture or compromising the alignment needed for surgery.
B. Log rolling the client and placing adult disposable briefs beneath them may not be suitable because it involves movement that can disrupt traction and worsen the client's pain.
Additionally, disposable briefs may not adequately manage urinary output, especially for a client awaiting surgery.

C.While using a catheter can be an option, it is generally not the first intervention unless the client is unable to void by other means or has a specific indication for catheterization. It carries risks, including infection, and should be considered carefully.
D. The nurse can assist the client in using a urinal while ensuring that traction is maintained. This allows the client to urinate without disrupting the traction setup, minimizing the risk of complications associated with the fracture.

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An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

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Naxlex Comprehensive Predictor Exams

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