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 C

Explanation

A. This statement suggests a delusion or hallucination, which are common symptoms of some mental disorders, but it does not specifically suggest an inability to process new information.
B. This statement suggests paranoia, which is a common symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
C. This statement suggests difficulty with memory, which is a cognitive function that is related to the ability to process new information.
D. This statement suggests a persistent negative mood, which is a symptom of some mental disorders, but it does not specifically suggest an inability to process new information.

A. Lower than normal expected reference range of body weight B. Amenorrhea C. Hyperkalemia D. Dental decay

Correct Answer is D

Explanation

A. Clients with bulimia nervosa may have a normal or above-normal body weight, as bulimia nervosa is characterized by episodes of binge eating followed by compensatory behaviors such as vomiting or excessive exercise.
B. Amenorrhea, or the absence of menstruation, is more commonly associated with anorexia nervosa rather than bulimia nervosa.
C. Hyperkalemia, or high levels of potassium in the blood, is not a common finding in clients with bulimia nervosa.
D. Frequent self-induced vomiting can lead to dental erosion and decay due to exposure of the teeth to stomach acid.

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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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Correct Answer is C

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A nurse is caring for a female client who has bulimia nervosa and reports frequent self-induced vomiting. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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immediate follow-up.)

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