Dependent edema

The nurse should identify that dependent edema is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system.

Jugular distention

The nurse should identify that jugular vein distention is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system.

Weight gain

The nurse should identify that weight gain is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system.

Frothy sputum

The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately.

Respiratory alkalosis

Question: 87 of 90

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Vitiligo

Vitiligo is the loss of pigment from areas of a client's skin, causing irregular, white patches. Vitiligo is a manifestation of adrenal-gland hypofunction.

Osteoporosis

Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner as a result of mineral loss and nitrogen depletion, and the risk for fractures increases.

Myxedema

A client who has hypothyroidism can develop myxedema that causes mucinous cellular edema around the eyes, across the upper back, and in the hands and feet.

Heat intolerance

A client who has hyperthyroidism can develop heat intolerance, along with an increase in sweating.

A pearly, waxy nodule

A is correct. The nurse should tap the client's cheek just in front of the ear and below the zygomatic arch. The client who has hypocalcemia will display a Chvostek's sign, which is a twitching of the facial muscle.

B is incorrect. The nurse should apply upward pressure at the supraorbital ridge, below the eyebrow, to assess for tenderness and inflammation of the frontal sinuses.

C is incorrect. The nurse should palpate the jaw and mastoid muscle of a client who has temporomandibular joint dysfunction. This can be caused by misaligned teeth, arthritis, or grinding of the teeth. With palpation, the nurse might feel a click, pop, or grating sensation when the client opens or closes the jaw.

High lipase

A high lipase level is associated with pancreatic dysfunction or renal failure and is not an expected finding with hyponatremia or dehydration.

Low urine specific gravity

MY ANSWEA client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity.

Low hemoglobin

A client who is dehydrated as a result of diuretic overuse can have an elevated hemoglobin level because of the difference in ratio between intravascular fluid and blood cells.

High creatine kinase-MB (CK-MB)

An elevated CK-MB level indicates a myocardial infarction and is not an expected finding with hyponatremia.

Remove clutter from rooms and hallways.

The nurse should instruct the family member to remove clutter from rooms and hallways so the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client.

Place a monthly calendar in the client's room.

MY ANSWEThe nurse should instruct the family member to place a single-date calendar in the client's room. A monthly calendar can be overwhelming and confusing to a client who has Alzheimer's disease.

Use confrontation to manage the client's behavior.

The nurse should instruct the family member to redirect the client by starting another activity when the client begins to act out or becomes overstimulated. Redirecting the client might help them gain focus.

Review the daily schedule with the client every morning.

The nurse should instruct the family member to use short, simple sentences when explaining an activity to the client. The explanation should be done immediately before the activity to aid the client's memory and ability to follow directions.