The nurse cares for a client with diabetes mellitus and congestive heart failure.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale: Chvostek and Trousseau signs are not typically associated with hypothyroidism.

Choice B rationale: These signs are not commonly related to pineal tumors.

Choice C rationale: Chvostek and Trousseau signs, indicating neuromuscular irritability due to hypocalcemia, are often seen in hypoparathyroidism.

Choice D rationale: Chvostek and Trousseau signs are not characteristic findings in pheochromocytoma.

A. Irregular respirations, bradycardia, and widening pressure B. Hypotension, jugular venous distention, and mufled heart sound C. Fixed pupils, hypertension, and bradycardia D. Bradycardia, hypotension, and bradypnea

Correct Answer is C

Explanation

Choice A rationale: Irregular respirations, bradycardia, and widened pulse pressure might indicate increased intracranial pressure.

Choice B rationale: This set of symptoms is often seen in cardiac tamponade and is referred to as the Beck’s triad and not Cushing's triad.

Choice C rationale: Cushing's triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes bradycardia (slow heart rate),

hypertension (elevated blood pressure), and irregular breathing patterns. Fixed pupils can also be present in some cases, but it's important to note that this triad is not always consistently present and may vary from person to person.

Choice D rationale: This set of symptoms describes symptoms of shock, not specifically Cushing's triad.

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The nurse cares for a client with diabetes mellitus and congestive heart failure. Exhibits Which two (2) client findings in the history and physical are most concerning? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes the final diagnosis of four clients in their case reports as given below. In which client does the nurse notice the presence of Chvostek sign and Trousseau sign?

Correct Answer is C

Explanation

The nurse is caring for a client with Cushing's triad. The nurse expects the client to have:

Correct Answer is C

Explanation

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The nurse is caring for a client who presents with acute appendicitis: Exhibits Select all that apply?

The nurse cares for a client with diabetes mellitus and congestive heart failure.

Exhibits

Which two (2) client findings in the history and physical are most concerning? Select all that apply