Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following?
A. Bronchitis
Bronchitis primarily causes coughing and mucus production, and does not specifically relate to trouble breathing while lying down.
B. Heart failure
Heart failure often leads to orthopnea (difficulty breathing while lying flat) and paroxysmal nocturnal dyspnea (waking up at night with difficulty breathing). These symptoms align with the client's reported issues.
C. Pneumonia
Pneumonia usually presents with acute symptoms such as cough, fever, and chest pain, rather than the specific nocturnal breathing difficulty described.
D. Tuberculosis
Tuberculosis typically involves symptoms like chronic cough, night sweats, and weight loss, rather than difficulty breathing while lying down.
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Full Explanation
A. Bronchitis primarily causes coughing and mucus production, and does not specifically relate to trouble breathing while lying down.
B. Heart failure often leads to orthopnea (difficulty breathing while lying flat) and paroxysmal nocturnal dyspnea (waking up at night with difficulty breathing). These symptoms align with the client's reported issues.
C. Pneumonia usually presents with acute symptoms such as cough, fever, and chest pain, rather than the specific nocturnal breathing difficulty described.
D. Tuberculosis typically involves symptoms like chronic cough, night sweats, and weight loss, rather than difficulty breathing while lying down.
Similar Questions
In an Electrocardiogram EKG tracing the P wave represents?
A. Ventricular Repolarization
Ventricular repolarization is represented by the T wave on an EKG.
B. Left arterial pressure
Left arterial pressure is not represented by any specific EKG waveform.
C. Ventricular Depolarization
Ventricular depolarization is represented by the QRS complex on an EKG.
D. Atrial Depolarization
The P wave represents atrial depolarization, which is the electrical activity that initiates atrial contraction.
Full Explanation
A. Ventricular repolarization is represented by the T wave on an EKG.
B. Left arterial pressure is not represented by any specific EKG waveform.
C. Ventricular depolarization is represented by the QRS complex on an EKG.
D. The P wave represents atrial depolarization, which is the electrical activity that initiates atrial contraction.
A mitral insufficiency/regurgitation murmur is classified as:
A. Flat murmur
A flat murmur does not accurately describe the type of murmur associated with mitral insufficiency.
B. Diastolic murmur
Mitral insufficiency is typically classified as a systolic murmur, not diastolic.
C. Absent murmur
An absent murmur would indicate no audible sound, which is not applicable here.
D. Systolic murmur
Mitral insufficiency or regurgitation is characterized by a systolic murmur due to the backflow of blood from the left ventricle into the left atrium during systole.
Full Explanation
A. A flat murmur does not accurately describe the type of murmur associated with mitral insufficiency.
B. Mitral insufficiency is typically classified as a systolic murmur, not diastolic.
C. An absent murmur would indicate no audible sound, which is not applicable here.
D. Mitral insufficiency or regurgitation is characterized by a systolic murmur due to the backflow of blood from the left ventricle into the left atrium during systole.
The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant. Which assessment should the nurse conduct next?
A. Palpate at McBurney's point for rebound tenderness.
Palpating McBurney's point for rebound tenderness helps evaluate for appendicitis, which is relevant given the client’s localized tenderness in the right lower quadrant.
B. Assess for Murphy's sign.
Murphy's sign is used to assess for gallbladder inflammation, which is not indicated by right lower quadrant pain.
C. Assess for Tinel sign.
The Tinel sign is used to assess for nerve irritation, not abdominal pain or appendicitis.
D. Test for a fluid wave.
Testing for a fluid wave is used to assess for ascites, which does not fit the presentation of localized right lower quadrant pain.
Full Explanation
A. Palpating McBurney's point for rebound tenderness helps evaluate for appendicitis, which is relevant given the client’s localized tenderness in the right lower quadrant.
B. Murphy's sign is used to assess for gallbladder inflammation, which is not indicated by right lower quadrant pain.
C. The Tinel sign is used to assess for nerve irritation, not abdominal pain or appendicitis.
D. Testing for a fluid wave is used to assess for ascites, which does not fit the presentation of localized right lower quadrant pain.