A 65-year-old patient with a history of heart failure comes to the clinic with complaints of 'being awakened from sleep with shortness of breath.' Which action by the nurse is most appropriate?

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Vital Signs Health Assessment Questions

Question 1 of 5

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of 'being awakened from sleep with shortness of breath.' Which action by the nurse is most appropriate?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next?

Correct Answer: C

Rationale: The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present. In the pregnant female, colostrum would be a thick, yellowish liquid, and it would be normally expressed after the fourth month of pregnancy.

Question 3 of 5

The component of the conduction system referred to as the pacemaker of the heart is the:

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

Which of the following would lead you to suspect a hydrocele versus other causes of scrotal swelling?

Correct Answer: C

Rationale: A cystic structure will often transilluminate well. While a transilluminator head for your battery handle is ideal, it is possible to use an otoscope to transilluminate the scrotum. You should be able to get above the mass on palpation and bowel sounds should not be present. If they are, it should lead you to consider an inguinal hernia. Scrotal edema involves thickened skin which can be measured by gently pinching a section of the scrotum itself.

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