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Exhibits

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Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

Client reports tightness in chest that radiates to left arm

States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast

Client is diaphoretic and short of breath

Heart rate irregular and tachycardic

I had scrambled eggs and bacon like I do every morning

Lungs clear to auscultation in all lobes

+1 pedal pulses

Capillary refill less than 2 seconds

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Client reports tightness in chest that radiates to left arm: Chest tightness that radiates to the left arm is a classic symptom of myocardial ischemia or infarction (heart attack). This symptom is concerning because it suggests potential heart muscle damage or decreased blood flow to the heart.

States pain as 7 on a scale of 0 to 10: The client rates their chest pain as 7 out of 10. This indicates significant discomfort and suggests that the chest tightness is causing substantial pain. Pain severity is an important indicator in assessing the severity of the cardiac event.

Started to feel nauseous after breakfast: Nausea can be a symptom associated with myocardial ischemia or infarction, particularly when it occurs after physical exertion or a meal. It can be caused by decreased blood flow to the gastrointestinal tract due to compromised cardiac function.

Client is diaphoretic and short of breath: Diaphoresis (excessive sweating) and shortness of breath are additional symptoms that commonly accompany acute myocardial infarction. Diaphoresis occurs due to sympathetic nervous system activation, while shortness of breath can result from decreased cardiac output or pulmonary congestion.

Heart rate irregular and tachycardic: An irregular and tachycardic (rapid) heart rate is abnormal and suggests cardiac dysrhythmia, which can occur in response to myocardial ischemia or infarction. It reflects the heart's attempt to compensate for reduced oxygen delivery to the body.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

D. This practice is recommended as a safety precaution to minimize the risk of radioactive contamination following treatment with radioactive isotopes. It helps to ensure that any residual radioactivity is contained and not inadvertently spread, which is particularly important in shared or public bathrooms.

A The recommended distance is typically at least 1 meter (approximately 3 feet), although specific guidelines may vary depending on the type and dose of radiation used.

B. The use of cloth handkerchiefs versus disposable tissues does not significantly affect radiation safety. The focus should be on minimizing contamination and ensuring proper disposal of any tissues or materials that come into contact with bodily fluids.

C. While managing incontinence appropriately is important for comfort and hygiene, it is not directly related to radiation safety. Clients should use standard incontinence products as needed, ensuring proper disposal and hygiene practices.

A. Projectile vomiting B. Papilledema C. Restlessness D. Decorticate posturing

Correct Answer is C

Explanation

C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.

A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.

B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.

D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

Correct Answer is C

Explanation

A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer?

Exhibits The nurse should plan to first administer dropdown followed by dropdown

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Exhibits Complete the following sentence by using the lists of options. The nurse should administer a total dropdown sodium chloride in the first hour, dropdown each subsequent hour.

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