A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it's typically due to:

Correct Answer: D

Rationale: Jugular vein distention (JVD)visible neck vein bulgingindicates elevated central venous pressure, typically from fluid overload (Choice D). This occurs when excess volume (e.g., heart failure, IV overload) backs up into the venous system, distending the jugular veins. Chest pain and shortness of breath align with this, suggesting cardiac strain (e.g., right heart failure). A neck tumor (Choice A) might compress veins, but JVD requires systemic pressure, not local obstruction, and lacks respiratory symptoms. Electrolyte imbalance (Choice B) affects cellular function, not directly venous pressure. Dehydration (Choice C) collapses veins, opposite to JVD. For example, in congestive heart failure, fluid retention raises venous return, causing JVD, detectable at 45° elevation. Fluid overload's pathophysiology fits the presentation, making Choice D the correct cause.

Correct Answer: A

Rationale: Stimulus control reconditions the bedroom as a sleep cue, per CBT-I protocols. 'Use the bedroom for sleep and sex only' is correct; limiting activitiese.g., no TV or workstrengthens the bed-sleep link, cutting sleep latency (e.g., from 40 to 15 minutes). Choice B, 'use the bedroom for reading and eating,' undermines this; multi-use (e.g., snacking at 10 p.m.) signals wakefulness, per sleep science. Choice C, 'go to bed at the same time every night,' is sleep hygiene, not stimulus control's coree.g., it's complementary, not defining. Choice D, 'sleep alone with minimal coverings,' is irrelevant; company or blankets don't dictate conditioning unless disruptive. For example, a patient leaving the bedroom if awake >20 minutes reinforces sleep association, per Taylor's behavioral approach. Choice A is the precise, correct recommendation.

Correct Answer: B

Rationale: Medication ordering reflects patient need and flexibility. 'P.r.n' , or 'as needed,' is most common for sleep medse.g., zolpidem 10 mg PRN allows use only when insomnia strikes, per hospital norms in Taylor. 'Stat' is immediate, one-timee.g., post-op, not routine sleep. 'Single order' is once-only, like stat, not ongoinge.g., one 5 mg dose. 'Daily dose' is schedulede.g., 10 mg qHSless common as it assumes constant need, risking tolerance. PRN's adaptabilitye.g., 3 nights weeklyfits sleep's variability, making Choice B the correct, prevalent method.

Correct Answer: B

Rationale: Pain location can mislead its origin. 'Referred pain' fits a myocardial infarction's left arm/shoulder paine.g., cardiac ischemia projects via shared nerve pathways (T1-T5), per Taylor's pain science. 'Cutaneous pain' is skin-specifice.g., a burn, not heart. 'Allodynia' is pain from non-painful stimulie.g., touch hurts in neuropathy, not MI. 'Nociceptive' is a category (tissue damage), not a typee.g., too broad here. MI's classic referrale.g., angina radiatingmakes Choice B the correct term.

Correct Answer: D

Rationale: Cultural competence in pain care respects diversity. 'Avoid stereotyping responses to pain by patients' is correcte.g., not assuming a stoic Asian patient feels less pain, per Taylor's cultural framework, ensures individualized assessment. Choice A, 'treat every patient the same,' ignores cultural normse.g., some groups (e.g., Hispanic) express pain vocally. Choice B, 'skilled in medication administration,' is technical, not culturale.g., giving morphine doesn't address beliefs. Choice C, 'know action and side effects,' is clinical knowledge, not competencee.g., unrelated to a patient's pain expression style. A nurse asking, 'How do you usually handle pain?'e.g., prayer for someavoids bias, aligning with holistic care. Choice D is the culturally adept answer.