A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Reinforce the importance of daily weights.

Call the health care provider for further instructions.

Document the findings and continue with the visit.

Ensure the client has been taking their prescribed diuretic.

Answer and Explanation

The Correct Answer is D

A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.

B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.

C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.

D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.

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Correct Answer is B

Explanation

A. This statement does not align with the typical behavior of a person with anorexia nervosa. People with anorexia nervosa often have a distorted body image and may fear gaining weight, but they do not typically avoid eating because they do not like the taste of food.
B. This statement is consistent with the behavior of a person with anorexia nervosa. People with this disorder often have specific foods that they fear or avoid because they associate them with gaining weight or losing control over their eating.
C. This statement may be true for some people with anorexia nervosa, but it is not a defining characteristic of the disorder. People with anorexia nervosa often restrict their food intake to a much lower level than 2,000 calories per day.
D. This statement does not align with the typical behavior of a person with anorexia nervosa. People with anorexia nervosa often obsessively track their calorie intake and may keep meticulous records of what they eat.

A. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." B. "Information about a client can be disclosed to family members at any time." C. "A client's address would be an example of personally identifiable information." D. "HIPAA is a federal law, not a state law." E. Trachea midline

Correct Answer is B

Explanation

A. This statement is correct. HIPAA protects the privacy and security of individually identifiable health information.
B. HIPAA generally requires patient authorization for the disclosure of health information to family members.
C. Personally identifiable information includes any information that can be used to identify an individual, such as a client's name, address, or social security number.
D. HIPAA is a federal law that sets national standards for the protection of health information.

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A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Nursing Test Bank

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