Recognizing Cues
A nurse is reviewing assessment findings for a client diagnosed with hypertension. Which finding should the nurse recognize as the most concerning cue requiring follow-up?
A. Blood pressure 148/88 mm Hg
B. Reports occasional headaches after work
C. New complaint of blurred vision and seeing spots
D. Heart rate 84/min
Correct Answer: C. New complaint of blurred vision and seeing spots
Rationale:
Visual disturbances may indicate target-organ damage or hypertensive urgency/emergency and require immediate follow-up. A blood pressure of 148/88 mm Hg is elevated but expected in a client with hypertension. Occasional headaches are common but less concerning. A heart rate of 84/min is within normal limits.
A nurse is reviewing assessment findings for a client with upper gastrointestinal pain. Which interpretation of the cues is most appropriate?
Assessment Findings:
A. Findings are most consistent with gastroesophageal reflux disease (GERD)
B. Findings are most consistent with a duodenal ulcer
C. Findings are most consistent with a gastric ulcer
D. Findings are most consistent with acute pancreatitis
Correct Answer: C. Findings are most consistent with a gastric ulcer
Rationale:
The nurse should analyze the relationship between pain and food intake. Gastric ulcer pain typically worsens shortly after meals, often leading to decreased food intake and weight loss. Duodenal ulcer pain generally improves with eating and occurs 2–4 hours after meals.
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with stable angina who reports chest pain after climbing stairs that resolves with rest
B. A client with unstable angina who reports chest pain at rest lasting 20 minutes
C. A client with hypertension and a blood pressure of 158/90 mm Hg
D. A client with heart failure who has 1+ pedal edema
Correct Answer: B. A client with unstable angina who reports chest pain at rest lasting 20 minutes
Rationale:
Chest pain occurring at rest is a hallmark of unstable angina and may indicate impending myocardial infarction. This client requires immediate assessment.
A nurse is providing discharge teaching to a client recovering from a myocardial infarction. Which statement by the client indicates an understanding of the teaching?
A. "I should stop taking my aspirin once I feel better."
B. "I can return to smoking if I only smoke a few cigarettes a day."
C. "I should report any chest pain that is not relieved by rest or nitroglycerin."
D. "I no longer need to monitor my blood pressure at home."
Correct Answer: C. "I should report any chest pain that is not relieved by rest or nitroglycerin."
Rationale:
Persistent chest pain may indicate recurrent ischemia and should be reported immediately. Aspirin therapy and risk factor modification are important components of secondary prevention.
A nurse administered nitroglycerin to a client experiencing chest pain related to a myocardial infarction.
Which finding indicates the intervention was effective?
A. Blood pressure decreased from 150/90 mm Hg to 138/84 mm Hg
B. Chest pain decreased from 8/10 to 2/10
C. Heart rate increased from 82/min to 104/min
D. Respiratory rate increased from 18/min to 24/min
Correct Answer: B. Chest pain decreased from 8/10 to 2/10
Rationale:
The desired outcome of nitroglycerin therapy is relief of myocardial ischemia and chest pain.
A nurse is assessing a client admitted with acute pancreatitis. Which assessment finding should the nurse recognize as the highest priority cue?
A. Reports nausea after eating
B. Serum lipase level of 450 U/L
C. Oxygen saturation of 89% on room air
D. Abdominal pain rated 8/10
Correct Answer: C. Oxygen saturation of 89% on room air
Rationale:
Acute pancreatitis can lead to respiratory complications such as acute respiratory distress syndrome (ARDS). An oxygen saturation of 89% indicates impaired oxygenation and requires immediate attention. Elevated lipase confirms pancreatitis but is expected. Pain and nausea are common manifestations.
A nurse is assessing a 14-year-old client. Which interpretation of the assessment findings is most appropriate?
Assessment Findings:
A. The findings suggest insulin resistance associated with type 2 diabetes mellitus
B. The findings suggest new-onset type 1 diabetes mellitus
C. The findings suggest syndrome of inappropriate antidiuretic hormone (SIADH)
D. The findings suggest chronic kidney disease
Correct Answer: B. The findings suggest new-onset type 1 diabetes mellitus
Rationale:
The nurse should recognize that hyperglycemia combined with weight loss and polyphagia indicates an inability to use glucose for energy due to insulin deficiency. This pattern is classic for new-onset type 1 diabetes.
A nurse is caring for a client admitted with an upper GI bleed. Which assessment finding requires immediate intervention?
A. Hemoglobin 11.2 g/dL
B. Black, tarry stools
C. Blood pressure 84/50 mm Hg and heart rate 126/min
D. Epigastric pain rated 5/10
Correct Answer: C. Blood pressure 84/50 mm Hg and heart rate 126/min
Rationale:
Hypotension and tachycardia suggest significant blood loss and possible hypovolemic shock. Maintaining circulation takes priority over pain management and diagnostic findings.
A nurse is teaching a client newly diagnosed with coronary artery disease about reducing cardiovascular risk factors. Which recommendation should the nurse include?
A. Increase intake of saturated fats
B. Engage in regular physical activity as tolerated
C. Eliminate all carbohydrates from the diet
D. Avoid taking prescribed cholesterol-lowering medications
Correct Answer: B. Engage in regular physical activity as tolerated
Rationale:
Regular exercise, smoking cessation, healthy nutrition, and medication adherence help reduce progression of coronary artery disease and decrease cardiovascular risk.
A nurse provides teaching to a client with GERD about lifestyle modifications.
Which statement by the client indicates the teaching has been effective?
A. "I drink peppermint tea before bed each night."
B. "I eat my largest meal right before going to sleep."
C. "I elevated the head of my bed and my nighttime symptoms have improved."
D. "I lie down for 30 minutes after eating to aid digestion."
Correct Answer: C. "I elevated the head of my bed and my nighttime symptoms have improved."
Rationale:
Improvement in reflux symptoms demonstrates that the intervention was successful.
A nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse recognize as requiring immediate provider notification?
A. Dry skin and coarse hair
B. Heart rate of 48/min
C. Reports weight gain of 10 lb over 3 months
D. Constipation for the past week
Correct Answer: B. Heart rate of 48/min
Rationale:
Severe bradycardia can indicate significant metabolic slowing and potential progression toward myxedema coma. Dry skin, weight gain, and constipation are expected findings in hypothyroidism.
A nurse is caring for a client with untreated hyperthyroidism. Which interpretation of the cues requires immediate action?
Assessment Findings:
A. The client is experiencing a panic attack
B. The client is experiencing worsening hypothyroidism
C. The client is experiencing thyrotoxicosis (thyroid storm)
D. The client is experiencing septic shock
Correct Answer: C. The client is experiencing thyrotoxicosis (thyroid storm)
Rationale:
The nurse should connect hyperthermia, severe tachycardia, hypertension, and altered mental status in a client with hyperthyroidism. These cues are characteristic of thyroid storm, a life-threatening endocrine emergency.
A nurse is caring for a client diagnosed with HHS. Which prescription should the nurse implement first?
A. Administer regular insulin infusion
B. Obtain a hemoglobin A1C level
C. Initiate intravenous 0.9% sodium chloride infusion
D. Provide diabetic diet education
Correct Answer: C. Initiate intravenous 0.9% sodium chloride infusion
Rationale:
The priority treatment for HHS is aggressive fluid replacement because severe dehydration and hypovolemia are the most immediate threats to life.
A nurse is providing discharge instructions to a client with cholelithiasis who is awaiting elective cholecystectomy. Which dietary choice indicates understanding of the teaching?
A. Fried chicken and french fries
B. Cheeseburger and onion rings
C. Grilled chicken, rice, and steamed vegetables
D. Pepperoni pizza
Correct Answer: C. Grilled chicken, rice, and steamed vegetables
Rationale:
A low-fat diet decreases gallbladder stimulation and can help reduce episodes of biliary colic.
A nurse treats a conscious client experiencing hypoglycemia with 15 g of rapid-acting carbohydrates.
Which finding indicates the intervention was effective?
A. Blood glucose increased from 52 mg/dL to 96 mg/dL
B. Urine ketones are present
C. Hemoglobin A1C is 8.2%
D. Blood glucose increased from 52 mg/dL to 280 mg/dL
Correct Answer: A. Blood glucose increased from 52 mg/dL to 96 mg/dL
Rationale:
The goal is to raise blood glucose to a safe range while resolving symptoms of hypoglycemia.
A nurse is reviewing laboratory results for a client with type 2 diabetes mellitus. Which finding should the nurse recognize as indicating worsening glycemic control?
A. Fasting blood glucose 128 mg/dL
B. Hemoglobin A1C 9.2%
C. LDL cholesterol 105 mg/dL
D. Blood pressure 132/80 mm Hg
Correct Answer: B. Hemoglobin A1C 9.2%
Rationale:
An A1C of 9.2% indicates poor long-term glucose control and increased risk for complications. Although the fasting glucose is elevated, the A1C provides a better assessment of overall glycemic control over the previous 2–3 months.
A nurse reviews the following assessment findings for a client with heart failure:
Assessment Findings:
Which interpretation is most appropriate?
A. The client is experiencing dehydration from diuretic therapy
B. The client is experiencing fluid volume overload related to worsening heart failure
C. The client is demonstrating expected findings of stable heart failure
D. The client is experiencing acute renal failure
Correct Answer: B. The client is experiencing fluid volume overload related to worsening heart failure
Rationale:
The nurse should analyze how rapid weight gain, edema, and pulmonary crackles collectively indicate fluid retention and worsening cardiac function. These findings are not consistent with dehydration.
A nurse is caring for a client with type 2 diabetes. Which finding should the nurse address first?
A. Hemoglobin A1C of 9.1%
B. Reports numbness in both feet
C. Blood glucose of 68 mg/dL with diaphoresis and shakiness
D. Reports difficulty following a diabetic diet
Correct Answer: C. Blood glucose of 68 mg/dL with diaphoresis and shakiness
Rationale:
Hypoglycemia is an acute, potentially life-threatening complication that requires immediate treatment. The other findings require follow-up but are not immediately life-threatening.
A nurse is teaching a client with gastroesophageal reflux disease (GERD). Which client statement indicates a need for further teaching?
A. "I will avoid eating right before bedtime."
B. "I will elevate the head of my bed."
C. "I will try to lose weight if I am overweight."
D. "I will drink peppermint tea after meals to help digestion."
Correct Answer: D. "I will drink peppermint tea after meals to help digestion."
Rationale:
Peppermint relaxes the lower esophageal sphincter and can worsen reflux symptoms. Weight loss, avoiding late meals, and elevating the head of the bed can improve GERD symptoms.
A client with cholelithiasis has been following a low-fat diet for 2 weeks.
Which outcome indicates the dietary intervention has been effective?
A. The client reports fewer episodes of right upper quadrant pain after meals.
B. The client gained 5 lb.
C. The client reports increased indigestion after eating fried foods.
D. The client reports persistent nausea after every meal.
Correct Answer: A. The client reports fewer episodes of right upper quadrant pain after meals.
Rationale:
Reducing dietary fat decreases gallbladder stimulation and often reduces biliary colic.
A nurse is assessing a client with suspected diabetic ketoacidosis (DKA). Which finding should the nurse recognize as the most significant cue supporting the diagnosis?
A. Blood glucose 410 mg/dL
B. Fruity breath odor and deep, rapid respirations
C. Increased thirst for the past week
D. Polyuria and nocturia
Correct Answer: B. Fruity breath odor and deep, rapid respirations
Rationale:
Fruity breath odor and Kussmaul respirations are hallmark findings of metabolic acidosis associated with DKA. Hyperglycemia, thirst, and polyuria occur in DKA but are not as specific for the diagnosis.
A nurse is assessing a client who underwent total knee replacement surgery 3 days ago.
Assessment Findings:
Which interpretation of the cues is most appropriate?
A. The client is experiencing expected postoperative discomfort
B. The client is demonstrating signs of compartment syndrome
C. The client is demonstrating signs of deep vein thrombosis
D. The client is experiencing peripheral arterial disease
Correct Answer: C. The client is demonstrating signs of deep vein thrombosis
Rationale:
The nurse should recognize the combination of unilateral swelling, warmth, tenderness, and recent surgery as a pattern consistent with DVT. These findings require prompt intervention to prevent pulmonary embolism.
A nurse is caring for a client with a bleeding gastric ulcer. Which action is the priority?
A. Administer prescribed proton pump inhibitor
B. Monitor stool for occult blood
C. Establish two large-bore IV catheters
D. Provide education regarding ulcer prevention
Correct Answer: C. Establish two large-bore IV catheters
Rationale:
A client with an active GI bleed is at risk for hypovolemia and shock. Establishing IV access allows for rapid fluid and blood product administration if needed.
A nurse is teaching a client with type 1 diabetes about sick-day management. Which instruction should the nurse include?
A. Skip insulin doses when unable to eat
B. Check blood glucose more frequently during illness
C. Drink only water until symptoms resolve
D. Stop monitoring ketones during illness
Correct Answer: B. Check blood glucose more frequently during illness
Rationale:
Illness often increases stress hormone production, leading to hyperglycemia. Clients should continue insulin therapy, monitor glucose frequently, maintain hydration, and check for ketones as directed.
A nurse teaches a client with coronary artery disease about exercise and risk factor modification.
Which finding best indicates the plan of care has been successful?
A. The client reports smoking one pack of cigarettes daily.
B. The client's LDL cholesterol increased from 130 mg/dL to 160 mg/dL.
C. The client walks 30 minutes five days per week and reports improved exercise tolerance.
D. The client discontinued prescribed atorvastatin because they feel better.
Correct Answer: C. The client walks 30 minutes five days per week and reports improved exercise tolerance.
Rationale:
Improved activity tolerance and adherence to lifestyle modifications demonstrate successful management of coronary artery disease.