BW is a 69-year-old African American male being evaluated by his health care team for a heart failure exacerbation. He is laying down when a physical exam is performed. Upon examination, you notice a large bulging vein in BW's neck. Upon further examination and measurement of the vein (>4 cm), BW was diagnosed with the following condition:
Bulging vein disorder
Jugular vein distension
Increased neck pressure
Jugular vein stenosis
The Correct Answer is B
A. Bulging vein disorder: This is not a recognized medical diagnosis and does not describe a specific pathophysiologic condition. Visible neck veins require interpretation within established cardiovascular assessment frameworks.
B. Jugular vein distension: Jugular vein distension occurs when elevated right atrial pressure causes venous blood to back up into the jugular veins. In heart failure exacerbations, increased central venous pressure leads to visible neck vein enlargement, especially when the client is supine. A measurement greater than 4 cm supports this finding.
C. Increased neck pressure: This is a nonspecific descriptive phrase rather than a clinical diagnosis. It does not identify the underlying cardiovascular mechanism responsible for venous engorgement.
D. Jugular vein stenosis: Jugular vein stenosis refers to narrowing of the vein, which would reduce venous flow rather than cause visible distension. It is not associated with heart failure–related volume overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ms. J, started on a new blood pressure medication 2 weeks ago. Her home blood pressure numbers average 120/70 with the new medicine and is considered controlled: The “Assess” step in the PPCP involves analyzing collected patient information to evaluate therapeutic outcomes, identify medication-related problems, and determine if treatment goals are met. Reviewing home BP readings to conclude the patient’s hypertension is controlled exemplifies this assessment.
B. The pharmacist prepares a list with the times of day the patient should take all of their prescription medications: Creating a medication administration schedule falls under the “Plan” or “Implement” steps, as it involves organizing and conveying instructions rather than analyzing data.
C. The pharmacist enters a list of the over-the-counter medications the patient takes on a regular basis into the pharmacy computer system: Documenting OTC use is part of “Collect” because it involves gathering patient medication information, not evaluating or interpreting it.
D. The pharmacist asks a patient about certain lifestyle factors (exercise, diet) while doing a history: Asking about lifestyle is part of the “Collect” step, as it gathers subjective data to inform later assessment.
E. When the pharmacist sees that a patient has a blood pressure of 140/95, the patient is scheduled for a return visit in 1 month: Scheduling follow-up is part of the “Follow-up/Monitor” step rather than assessment. It responds to findings rather than analyzing them for therapeutic effectiveness.
Correct Answer is A
Explanation
A. Rectal: Rectal temperature measurement provides core body temperature and is considered the most accurate reflection of internal body heat. It is less influenced by environmental factors and provides reliable readings for clinical assessment.
B. Axillary: Axillary temperature is taken under the arm and tends to be lower than core temperature. It is easy and noninvasive but less accurate due to heat loss to the environment and variations in placement.
C. Oral: Oral temperature is convenient and reasonably accurate in cooperative patients but can be affected by recent food or fluid intake, mouth breathing, or smoking. It does not always reflect true core temperature.
D. Temporal: Temporal artery thermometry is noninvasive and quick but can be influenced by sweating, ambient temperature, and improper technique, making it slightly less precise than rectal measurement for core temperature.
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