A nurse obtains the health history of a client who is newly ...

[sheilaspns]

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
 
  a. I wake up to go to the bathroom at night.
  b. My shoes fit tighter by the end of the day.
  c. I seem to be feeling more anxious lately.
  d. I drink at least eight glasses of water a day.

Question 2

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
 
  a. Excruciating pain on inspiration
  b. Left lateral chest wall pain
  c. Disorientation and confusion
  d. Numbness and tingling of the arm

[steff9894]

Answer to Question 1

ANS: B
Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

Answer to Question 2

ANS: C
In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.