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Patient Data

The nurse completed vital signs and a physical exam.
Click to highlight the findings that need further evaluation by the nurse.

Nursing Assessment

Cardiovascular: Tachycardia. 2+ radial and pedal pulses. 2 second capillary refill.

Respiratory: Clear breath sounds throughout bilateral lungs.

Gastrointestinal Distended abdomen. Reported diarrhea. Denies nausea.

Genitourinary: Within normal limits (WNL) per report of client.

Integumentary: Jaundice. Spider angiomas to the chest and abdomen. Generalized bruising in various states of healing.

Tachycardia

2+ radial and pedal pulses

2 second capillary refill

Clear breath sounds throughout bilateral lungs

Distended abdomen

Reported diarrhea

Denies nausea

Within normal limits (WNL) per report of client

Jaundice

Spider angiomas to the chest and abdomen

Generalized bruising in various states of healing

Answer and Explanation

The Correct Answer is ["A","E","I","J","K"]

Rationale:

• Tachycardia: Elevated heart rate may indicate dehydration, early sepsis, anemia, or compensatory response to liver dysfunction. In chronic alcohol use, tachycardia can signal systemic stress, possible electrolyte imbalance, or early signs of hepatic decompensation. Further evaluation is needed to determine the underlying cause and guide interventions.

• Distended abdomen: Abdominal distention can indicate ascites, organomegaly, or gastrointestinal bleeding, all common in chronic liver disease. Assessment for fluid wave, shifting dullness, and tenderness is essential. This finding requires further evaluation to prevent complications like spontaneous bacterial peritonitis or respiratory compromise.

• Jaundice: Yellowing of the sclera and skin indicates hyperbilirubinemia, often due to impaired liver function. Jaundice can reflect acute or chronic hepatocellular injury, biliary obstruction, or hemolysis. Determining the etiology through laboratory testing (bilirubin, liver enzymes) is critical for management and prognosis.

• Spider angiomas: These vascular lesions suggest chronic liver disease and altered estrogen metabolism. While often benign, their presence signals underlying hepatic dysfunction and warrants further assessment. They help the nurse identify the severity and chronicity of liver involvement.

• Generalized bruising in various stages of healing: Easy bruising may reflect coagulopathy associated with liver disease, vitamin K deficiency, or thrombocytopenia. Multiple stages of bruising raise concern for both medical and social factors, including possible trauma or neglect. Assessment of platelet count, coagulation studies, and safety is necessary.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Imbalanced Nutrition: less than body requirements: Malnutrition is the most immediate threat to life in adolescents with anorexia nervosa. Addressing inadequate nutrition is critical to prevent complications such as electrolyte imbalances, cardiac arrhythmias, and organ failure, making it the highest priority.

B. Interrupted Family Processes: Family dysfunction can contribute to the disorder, but it is not an immediate threat to the client’s physical health. It is a secondary concern to nutritional stabilization.

C. Noncompliance with treatment regimen: Noncompliance affects long-term outcomes, but the immediate risk from malnutrition takes precedence. Interventions for compliance follow stabilization.

D. Disturbed Body Image: Body image concerns are central to anorexia nervosa but primarily affect psychosocial health. While important for therapy, they are not the most urgent nursing problem compared with physiological risk.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Rationale:

• Red spots with bluish center: These lesions represent Koplik spots, which are a classic early finding seen on the buccal mucosa in measles. They appear before the widespread rash and are considered highly specific for this viral infection. Their presence helps distinguish measles from other childhood exanthems.

• Tachycardia: Tachycardia in this child is most likely a physiological response to fever rather than a disease-specific indicator. Many pediatric infections can cause elevated heart rate, making it nonspecific. It does not help differentiate between measles, rubella, or chicken pox. Therefore, it is not the most meaningful symptom for identifying the cause.

• Maculopapular rash: A maculopapular rash can be seen in both measles and rubella, making it less specific for a single diagnosis. Without additional distinguishing features, this rash pattern alone cannot confirm measles. The rash distribution is helpful but not diagnostic on its own. More specific signs are needed for accurate identification.

• Measles: Measles commonly presents with high fever, cough, anorexia, and a maculopapular rash that begins on the face and spreads downward. The presence of Koplik spots is a key diagnostic clue unique to measles. The child’s elevated temperature and respiratory symptoms further support this condition.

• Chicken pox: Chicken pox is characterized by vesicular lesions in different stages of healing rather than a maculopapular rash. It does not cause Koplik spots in the mouth. Respiratory symptoms such as cough are also less prominent. These differences make chicken pox an unlikely cause in this case.

• Rubella: Rubella can cause a maculopapular rash and mild fever but is typically associated with milder symptoms overall. Koplik spots are not seen in rubella. Respiratory symptoms like cough are less common and less severe. The presence of bluish-white oral lesions rules out rubella.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is A

Explanation

Patient Data Based on the client's symptoms, the nurse is considering what might be causing them. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse determines that the symptom of dropdown indicates dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Patient Data Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of dropdown explained by assessment findings of dropdown and dropdown.

Patient Data Based on the client’s history and clinical findings, which of the following laboratory tests should the nurse anticipate the provider will order first?

Patient Data The nurse considers the client's symptoms. Which assessment finding(s) support the suspected diagnosis of acute stroke? Select all that apply.

The nurse is providing client teaching about the use of a patient-controlled analgesia (PCA) pump. Which statement by the client indicates the need for more instruction about the PCA pump?

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is preparing a client for discharge who was hospitalized with a flare of symptoms from rheumatoid arthritis. Which instruction is most important for the nurse to include?

An adult male client is brought to the emergency department (ED) by ambulance following a motorcycle collision. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?