Assessment of a Patient
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Question 1 of 5.
The nurse is performing a cardiovascular assessment on a client. Which item should the nurse assess to obtain the best information about the client's left-sided heart function?
A. The status of breath sounds
B. The presence of peripheral edema
C. The presence of hepatojugular reflux
D. The presence of jugular vein distention
Explanation: The client with heart failure may present different symptoms depending on whether the right or the left side of the heart is failing. The assessment of breath sounds provides information about left-sided heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-sided heart function.
Question 2 of 5.
Which data should the nurse expect to obtain during the admission assessment of a child to support the diagnosis of irritable bowel syndrome?
A. Frequent incidents of frothy diarrhea
B. Frequent foul-smelling ribbon stools
C. Profuse, watery diarrhea and vomiting daily
D. Diffuse abdominal pain unrelated to meals or activity
Explanation: Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted. Option 1 is a clinical manifestation of lactose intolerance. Option 2 is a clinical manifestation of Hirschsprung's disease. Option 3 is a clinical manifestation of celiac disease.
Question 3 of 5.
The nurse caring for a child diagnosed with rubeola (measles) notes that the primary health care provider has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
A. Pinpoint petechiae noted on both legs
B. Whitish vesicles located across the chest
C. Petechiae spots that are reddish and pinpoint on the soft palate
D. Small, blue-white spots with a red base found on the buccal mucosa
Explanation: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Based on this information, the remaining options are all incorrect.
Question 4 of 5.
Which assessment finding should the nurse expect to note in the child hospitalized with a diagnosis of nephrotic syndrome?
A. Weight loss
B. Constipation
C. Hypotension
D. Abdominal pain
Explanation: Clinical manifestations associated with nephrotic syndrome include edema, anorexia, fatigue, and abdominal pain from the presence of extra fluid in the peritoneal cavity. Diarrhea caused by the edema of the bowel occurs and may cause decreased absorption of nutrients. Increased weight from fluid buildup and a normal blood pressure are noted.
Question 5 of 5.
A child is admitted to the hospital with a suspected diagnosis of von Willebrand's disease. On assessment of the child, which symptom would most likely be noted?
A. Hematuria
B. Presence of hematomas
C. Presence of hemarthrosis
D. Bleeding from the mucous membranes
Explanation: The primary clinical manifestations of von Willebrand's disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, may be the first evidence of abnormal hemostasis in those with mild disease. In females, menorrhagia and profuse postpartum bleeding may occur. Bleeding associated with von Willebrand's disease may be severe and lead to anemia and shock, but unlike what is seen in clients with hemophilia, deep bleeding into joints and muscles is rare. Options 1, 2, and 3 are characteristic of those signs found in clients with hemophilia.