Mrs. Helms is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?

Improper positioning

Fatigue or weakness

Respiratory distress

Increased comfort and relaxation

Answer and Explanation

The Correct Answer is C

A.   Improper positioning does not apply in this case; the position described is often associated with respiratory distress.
B.   Fatigue or weakness may be present, but the described position is more indicative of difficulty breathing.
C.   Respiratory distress is suggested by the patient leaning forward, which is a common position for patients with shortness of breath as it helps expand the lungs and ease breathing.
D.   Increased comfort and relaxation is unlikely; this position is more often associated with discomfort and difficulty breathing.

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Correct Answer is B

Explanation

A. Exophthalmos, or bulging eyes, is associated with hyperthyroidism (such as in Graves' disease), not acromegaly.
B. This is a hallmark sign of acromegaly. People with acromegaly often develop coarse, enlarged facial features (e.g., thickened lips, enlarged nose, protruding jaw, and enlarged tongue), which occur due to excess growth hormone.
C. While acromegaly can cause abnormal bone growth, especially in the hands and feet, it does not typically result in bowed long bones. This would be more suggestive of conditions like rickets or osteomalacia.
D. While acromegaly can lead to changes in the skull, it does not typically result in a distinctly acorn- shaped cranium. This is not a primary diagnostic feature of acromegaly.

A. Peripheral vascular disease B. Fluid and electrolyte disturbances C. Heart failure D. Atrial-septal defect

Correct Answer is C

Explanation

A. Peripheral vascular disease involves issues with blood flow to the extremities but does not typically present with jugular vein distension or a gallop heart sound.
B. Fluid and electrolyte disturbances may affect heart rhythm and fluid balance but are less likely to present with these specific findings.
C. Heart failure is the most likely cause, as jugular vein distension and a third heart sound (S3 gallop) are common signs of heart failure, particularly when the heart cannot effectively pump blood.
D. Atrial-septal defect may cause heart murmurs or irregular rhythms but is not typically associated with jugular vein distension or an S3 gallop.

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Mrs. Helms is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion?

Correct Answer is B

Explanation

During a cardiac assessment of a client you observed jugular vein distension, and auscultated $3 gallop heart sound. These findings most likely suggest which of the following conditions?

Correct Answer is C

Explanation

Which of the following is the most important muscle in the normal respiratory process of an adult?

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another?

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A heart murmur should be assessed for which of the following? Select all that apply.

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