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Questions 227

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Extract:

This is a 70-year-old male patient admitted due to hiccups, confusion, right arm & right leg weakness, facial droop and slurred speech. He has an Hx of CAD & had the 2nd CABG about 4 years ago.


Question 1 of 5

The nurse is aware that clinical manifestations differentiate right CHF from left CHF. Symptoms of right CVA would include:

Correct Answer: A

Rationale: Right-sided symptoms like jugular vein distension are unrelated to CVA; question likely meant right CHF.

Extract:


Question 2 of 5

A nurse is caring for a newborn who is 2 hours old. Which of the following findings should be reported to the healthcare provider?

Correct Answer: B

Rationale: Jaundice within 24 hours of birth is pathologic, indicating possible hemolytic disease or liver issues, requiring reporting. Heart rate, respiratory rate, and temperature are normal for a newborn.

Question 3 of 5

Which of the following might be an appropriate nursing diagnosis for an epileptic client?

Correct Answer: B

Rationale: Epilepsy increases the risk of injury due to seizures, which can cause falls or trauma. The other diagnoses are not directly related to epilepsy. Reduction of Risk Potential

Question 4 of 5

A nurse is teaching a patient about a low-sodium diet. Which of the following foods should the patient avoid?

Correct Answer: B

Rationale: Canned soups are high in sodium, worsening conditions like hypertension or heart failure. Fresh fruits, whole grains, and lean meats are low-sodium and appropriate for the diet.

Extract:

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte balance?


Question 5 of 5

Skin turgor

Correct Answer: B

Rationale: Intake and output provide the most direct measure of fluid balance.

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