Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?
A. Dependent edema
Dependent edema is characterized by swelling in the lower extremities due to gravity and may not always present with pigmentation changes.
B. Stasis ulceration
Stasis ulceration involves ulcerative lesions typically occurring on the lower legs, often associated with venous insufficiency, but the pigmentation alone does not confirm ulceration.
C. Arterial occlusion
Arterial occlusion typically presents with symptoms such as pain, pallor, and decreased pulses, not necessarily with warm skin and brown pigmentation.
D. Venous insufficiency
Venous insufficiency is characterized by symptoms such as warm skin, brown pigmentation around the ankles (due to hemosiderin deposition from blood pooling), and swelling.
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Full Explanation
A. Dependent edema is characterized by swelling in the lower extremities due to gravity and may not always present with pigmentation changes.
B. Stasis ulceration involves ulcerative lesions typically occurring on the lower legs, often associated with venous insufficiency, but the pigmentation alone does not confirm ulceration.
C. Arterial occlusion typically presents with symptoms such as pain, pallor, and decreased pulses, not necessarily with warm skin and brown pigmentation.
D. Venous insufficiency is characterized by symptoms such as warm skin, brown pigmentation around the ankles (due to hemosiderin deposition from blood pooling), and swelling.
Similar Questions
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.
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.
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.