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 D
Explanation
Choice A rationale: Used in the management of hepatic encephalopathy by reducing the production of ammonia in the gut.
Choice B rationale: Often prescribed to reduce ammonia levels in hepatic encephalopathy by promoting bowel movements and aiding ammonia excretion. Choice C rationale: Typically used in managing ascites by reducing fluid retention and treating edema.
Choice D rationale: This medication can potentially worsen hepatic encephalopathy due to its sedative effects and impact on mental function. It's crucial to clarify its use in a patient with hepatic encephalopathy.
Correct Answer is A
Explanation
Choice A rationale: Petit mal seizures, also known as absence seizures, involve a sudden lapse in consciousness for a brief duration, typically 5 to 30 seconds.
Choice B rationale: Clonic seizures involve rhythmic jerking movements.
Choice C rationale: Tonic-clonic seizures involve both tonic (muscle stiffness) and clonic (rhythmic jerking) phases.
Choice D rationale: Tonic seizures involve muscle stiffness but don't usually present as sudden lapses of consciousness in a short duration.
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