At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Constipation

Indigestion

Swollen ankles

Urinary frequency

None

Answer and Explanation

The Correct Answer is B

A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.

B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.

C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."

D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.

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Correct Answer is A

Explanation

A. A BMI of 20 falls within the healthy weight range for adults, indicating that the client's weight is appropriate for his height.

B. A BMI of 20 is not indicative of malnutrition. Malnutrition is typically associated with lower BMIs.

C. A BMI of 20 is not within the overweight range, as overweight is typically defined as a BMI between 25 and 29.9.

D. A BMI of 20 is not within the obesity range, as obesity is typically defined as a BMI of 30 or higher.

A. asymmetric, with variegated coloring B. scaly and red C. brown, with a wart-like texture D. firm and rubbery

Correct Answer is A

Explanation

A. Asymmetric lesions with variegated (multiple) colors are characteristic features of melanoma, a type of skin cancer. Asymmetry means one half of the lesion does not match the other half in size, shape, or color.

B. Scaly and red lesions may indicate other skin conditions such as eczema or psoriasis but are not specific to skin cancer.

C. Brown lesions with a wart-like texture may indicate seborrheic keratosis, a benign skin growth, rather than skin cancer.

D. Firm and rubbery lesions may indicate benign skin tumors such as fibromas or lipomas, rather than skin cancer.

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At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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