A client with congestive heart failure presents with swollen ankles, legs, and abdomen. The nurse should document these findings as:
Clubbing
Peripheral edema
Pitting edema
Ascites
The Correct Answer is B
A) This choice is incorrect because clubbing refers to the enlargement of the fingertips and nails due to chronic hypoxia, which is not related to the client's reported symptoms.
B) This choice is correct. Peripheral edema refers to swelling in the legs, ankles, and feet, which is a common symptom of congestive heart failure. The client's symptoms of swollen ankles, legs, and abdomen indicate peripheral edema.
C) This choice is incorrect because pitting edema is a specific type of edema where pressure on the skin leaves an indentation or "pit." While the client's edema may indeed be pitting, the question does not provide enough information to confirm this.
D) This choice is incorrect because ascites is the accumulation of fluid in the abdominal cavity and is not specific to the client's reported symptoms of swollen ankles and legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) This choice is incorrect because ACE inhibitors should not be taken with grapefruit juice. Grapefruit juice can interfere with the metabolism of the medication, leading to increased levels and potential side effects.
B) This choice is incorrect because the client should not adjust the dose of the ACE inhibitor without consulting their healthcare provider. Blood pressure should be monitored, but any dosage adjustments should be made by the healthcare provider based on the client's response to the medication.
C) This choice is correct. ACE inhibitors can cause a side effect of a persistent dry cough, and in some cases, difficulty breathing. The client should promptly report these symptoms to their healthcare provider for evaluation and possible adjustment of the medication regimen.
D) This choice is incorrect because while ACE inhibitors can increase potassium levels, avoiding foods high in potassium is not necessary unless specifically directed by the healthcare provider. The client should follow a balanced diet and inform the healthcare provider of any changes in their dietary habits.
Correct Answer is D
Explanation
A) This choice is incorrect because hypernatremia (high sodium levels) is not a common adverse effect of loop diuretics. Loop diuretics primarily impact sodium and water excretion.
B) This choice is incorrect because hyperkalemia (high potassium levels) is not typically associated with loop diuretics. In fact, loop diuretics can lead to increased potassium excretion, potentially causing hypokalemia.
C) This choice is incorrect because hypocalcemia (low calcium levels) is not a common adverse effect of loop diuretics. Loop diuretics primarily affect sodium, potassium, and water excretion.
D) This choice is correct. Loop diuretics are potent potassium-wasting diuretics, meaning they increase potassium excretion in the urine, potentially causing hypokalemia. The nurse should closely monitor the client's potassium levels and provide potassium supplementation if necessary.
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