Guide.
1. The nurse is taking the 1. Increase in Forced Vital Capacity (FVC)
health history of a
Forced Vital Capacity is the volume of air exhaled from
patient being treated for full inhala- tion to full exhalation. A patient with COPD
Emphyse- ma and would have a decrease in FVC. Incorrect.
Chronic Bronchitis.
After being told the
patient
has been smoking cigarettes 2. A narrowed chest cavity
for 30 years, the nurse A patient with COPD often presents with a 'barrel chest,'
ex- pects to note which which is seen as a widened chest cavity. Incorrect.
assess- ment finding?
3. Clubbed fingers - CORRECT
1. Increase in Forced Clubbed fingers are a sign of a long-term, or chronic,
Vital Capacity (FVC) decrease in oxygen levels.
2. A narrowed chest
cavity 4. An increased risk of cardiac failure
3. Clubbed fingers Although a patient with these conditions would indeed be
4. An increased risk of at an increased risk for cardiac failure, this is a potential
car- diac failure complication and not an assessment finding. Incorrect.
2. The nurse is 1. Melena - CORRECT
taking the health Melena is the finding that there are traces of blood in
history of a the stool which presents as black, tarry feces. This is a
70-year-old patient common manifesta-
being
treated for a Duodenal Ulcer. tion of Duodenal Ulcers, since the Duodenum is
further down the
After being told the gastric anatomy.
patient is complaining
of epigastric pain, the 2. Nausea
nurse expects to
note which assessment find- Nausea may be present, but is a generalized
symptom and by
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Guide.
ing? itself doesn't indicate a Duodenal Ulcer. Incorrect.
1. Melena 3. Hernia
2. Nausea A Hernia is a protrusion of a segment of the abdomen
3. Hernia through another abdominal structure. It is not associated
4. Hypertherm with an Ulcer and is a condition, not an assessment
ia
finding. Incorrect.
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Guide.
4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment
finding of a Duodenal Ulcer. Incorrect
3. A nurse is providing 1. "I'm going to limit my meals to 2-3 per day to
dis- charge teaching reduce acid secretion."
for a pa- tient with CORRECT - Large meals increase the volume and
severe Gastroe- pressure in the stomach and delay gastric emptying.
sophogeal Reflux It's recommended instead to eat 4-6 small meals a day.
Disease. Which of these
statements by the 2. "I'm going to make sure to remain upright after
patient indicates a meals and elevate my head when I sleep"
need for more Incorrect - This is a correct verbalization of health promotion
teaching? for GERD.
1. "I'm going to limit 3. "I won't be drinking tea or cottee or eating chocolate
my meals to 2-3 per any
day to re- duce acid
secretion."
2. "I'm going to make sure to more."
remain upright after Incorrect - This is a correct verbalization of health
meals and elevate my promotion for GERD.
head when I sleep"
4. "I'm going to start trying to lose some weight."
3. "I won't be drinking Incorrect - This is a correct verbalization of health
tea promotion for
or coffee or eating chocolate GERD.
any more."
4. "I'm going to start
trying to lose some
weight."
4. The nurse in the Emergency Room is treating a
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Guide.
patient suspected to 1. Start a large-bore IV in the patient's arm
have a Peptic Ulcer. On
CORRECT - The nurse should suspect that the patient is
assessing lab re- sults,
haemor- rhaging and will need need a fluid replacement
the nurse finds that
therapy, which requires a large bore IV.