The nurse cares for a client with diabetes mellitus and congestive heart failure.
Which two (2) client findings in the history and physical are most concerning? Select all that apply
Oral temperature
Thready pulse
Reports of thirst
Recently lost his job
Medical history of CHF
Correct Answer : B,D
Choice A rationale: While the temperature is important in assessing health, it isn't the most concerning finding in this scenario compared to others.
Choice B rationale: A thready pulse (a weak, barely palpable pulse) could indicate a critical drop in blood pressure and cardiac output, which is a significant concern.
Choice C rationale: While indicating a possible issue with hydration, it's not as immediately concerning as other findings in this context.
Choice D rationale: Recently lost his job - While this has social and economic implications, it's not an immediate physiological concern in this clinical scenario.
Choice E rationale: While significant in his overall health, it's not a direct finding from the current assessment that immediately raises concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Considering the mechanism of injury, pain severity, tenderness, swelling, and ecchymosis, there is a high suspicion of a fracture. Immobilization is essential to prevent further injury and reduce pain.
Choice B rationale: Contracture is less likely in this acute injury scenario. Acetaminophen might manage pain, but it doesn't address the risk factor.
Choice C rationale: A sprain is less likely given the severity of pain and the mechanism of injury. Raising the leg doesn't address the risk of a suspected fracture.
Choice D rationale: Dislocation doesn't align with the reported symptoms. Applying heat could potentially worsen inflammation.
Correct Answer is C
Explanation
Choice A rationale: Clients with Graves' disease may have increased sensitivity to light due to ocular manifestations like photophobia, so keeping the room well-lit may can cause eye irritation.
Choice B rationale: Encouraging frequent ambulation and exercise may worsen the symptoms of hyperthyroidism, such as tachycardia, palpitations, and tremors.
Choice C rationale: This is because clients with Graves' disease have an increased
metabolic rate and may experience weight loss, muscle wasting, and fatigue. A high- calorie and high protein diet can help prevent these complications and provide adequate nutrition for the client.
Choice D rationale: Placing extra blankets over the client may increase the body temperature and cause heat intolerance, which is another common symptom of Graves' disease.
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