a nurse is assessing a client whose therapy has included bed rest for several weeks which of the following findings should the nurse identify as the p
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1. A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?

Correct answer: D

Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.

2. A client in an oncology clinic is being assessed by a nurse while undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

Correct answer: A

Rationale: Choice A is the correct answer as nightmares about upcoming surgery indicate psychological distress commonly associated with fears, anxiety, and stress related to the treatment. Choices B, C, and D suggest positive emotions and proactive behaviors that are not typical signs of psychological distress in this context. Feeling more energetic, making future plans, and looking forward to treatment are generally positive indicators of coping and adjustment to the situation.

3. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

Correct answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

4. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?

Correct answer: C

Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.

5. A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?

Correct answer: C

Rationale: The correct answer is C: Increased breath sounds. When a client with pneumonia is receiving antibiotic therapy, increased breath sounds indicate that the lungs are clearing and the pneumonia is resolving. This improvement in breath sounds suggests that the antibiotics are effectively treating the infection. Choices A, B, and D are incorrect because a decreased white blood cell count, decreased respiratory rate, and increased heart rate are not specific indicators of the effectiveness of antibiotic therapy in treating pneumonia. While these parameters may change in response to treatment, they do not directly reflect the resolution of the pneumonia infection.

Similar Questions

The healthcare provider is caring for a client receiving chemotherapy. Which finding should the LPN/LVN report to the healthcare provider immediately?
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?
A client requires a 24-hour urine collection. Which statement by the client indicates an understanding of the teaching?
The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?
The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

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