A client with heart failure requests two more pillows to sleep with at night. Which area should the practical nurse (PN) evaluate when responding to the client's request?
Neuro vital signs.
Urinary output.
Blood pressure.
Breath sounds.
The Correct Answer is D
Choice A reason: Evaluating neuro vital signs includes assessing the client's level of consciousness, pupil response, motor function, and other neurological indicators. While important for overall assessment, changes in neurological status are not the most immediate concern in the context of heart failure and the client's request for more pillows. The request may be related to orthopnea, a common symptom of heart failure where clients experience difficulty breathing while lying flat.
Choice B reason: Monitoring urinary output is crucial for assessing kidney function and fluid balance, especially in clients with heart failure. However, it does not directly address the client's symptom of needing more pillows to sleep, which is more likely related to respiratory discomfort. While maintaining adequate urinary output is important, it is not the primary assessment needed in this scenario.
Choice C reason: Blood pressure is a vital sign that needs regular monitoring in clients with heart failure, as it can indicate fluid status and cardiac function. However, the need for additional pillows to sleep is more directly related to respiratory issues rather than blood pressure alone. While important, it is not the primary focus in response to the client's specific request.
Choice D reason: Evaluating breath sounds is the most relevant assessment when a client with heart failure requests more pillows to sleep. This request often indicates orthopnea, where the client has difficulty breathing while lying flat due to fluid accumulation in the lungs (pulmonary congestion). By assessing breath sounds, the PN can detect signs of crackles, wheezing, or decreased air entry, which may indicate worsening heart failure or pulmonary edema. Prompt assessment and intervention are crucial to address respiratory distress and prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Smoking two packs of cigarettes a day is highly significant in planning the client's rehabilitation following a myocardial infarction. Smoking is a major risk factor for cardiovascular disease, and continuing to smoke can significantly hinder recovery and increase the risk of future cardiac events. Addressing this behavior is crucial for improving the client's long-term health outcomes. Smoking cessation should be a primary focus of the rehabilitation plan, and the client should be provided with resources and support to quit smoking, such as counseling, nicotine replacement therapy, or medications.
Choice B reason: Expressing a desire to change one's lifestyle is a positive and encouraging sign. It indicates the client's motivation to adopt healthier habits, which is essential for successful rehabilitation. However, while this is important, the immediate focus should be on addressing specific risk factors, such as smoking, that have a direct and significant impact on the client's recovery and future health. The desire to change is a valuable component of the rehabilitation process, but it should be coupled with targeted interventions to address critical behaviors like smoking.
Choice C reason: Drinking 1 to 2 glasses of red wine daily may have both positive and negative health implications. Moderate alcohol consumption has been suggested to have some cardiovascular benefits, but it can also pose risks, especially if not monitored. While this information is relevant to the client's overall lifestyle, it is not as immediately critical as addressing smoking, which has a well-documented and direct impact on cardiovascular health. The client's alcohol consumption can be discussed as part of the broader lifestyle changes during rehabilitation.
Choice D reason: Walking four city blocks to work each day indicates a level of physical activity that is beneficial for cardiovascular health. Encouraging regular physical activity is an essential part of the rehabilitation process. However, compared to the impact of smoking, this information is less critical in the immediate planning of the client's rehabilitation. The focus should be on eliminating harmful behaviors like smoking, while also promoting continued and possibly increased physical activity as part of a comprehensive rehabilitation plan.
Correct Answer is D
Explanation
Choice A reason: This describes an electroencephalogram (EEG), not an ECG. An EEG detects and maps electrical activity in areas of the brain, which is useful for diagnosing conditions such as epilepsy and other brain disorders.
Choice B reason: This describes a computed tomography (CT) scan. A CT scan uses X-rays and a computer to produce detailed images of internal organs and structures. It is not related to the electrical activity of the heart.
Choice C reason: This describes an electromyography (EMG) test or an auditory brainstem response (ABR) test. EMG records electrical activity in muscles, while ABR measures eye and muscle responses to sounds to evaluate the auditory pathways in the brainstem. Neither of these tests is related to recording heart function.
Choice D reason: A 12-lead ECG graphs the electrical impulses generated by the heart as it beats. This test helps evaluate the heart's rhythm, detect any abnormalities, and diagnose various heart conditions such as arrhythmias, myocardial infarctions, and other cardiac issues. By capturing the electrical activity from different angles, the ECG provides a comprehensive picture of the heart's functioning.
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