A home health nurse is collecting data from 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?

Document the findings and continue with the visit.

Notify the RN case manager of the change in status.

Reinforce the importance of daily weights.

Ensure the client has been taking their prescribed diuretic.

Answer and Explanation

The Correct Answer is B

A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.

B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.

C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.

D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.

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Correct Answer is D

Explanation

A. While it may be wise to avoid driving if experiencing symptoms, asking for assistance in general does not specifically address the risk of sudden cardiac death.
B. Frequent hiccups are not a common indication or symptom directly related to arrhythmogenic cardiomyopathy or its risks.
C. Constipation is not directly related to arrhythmogenic cardiomyopathy or the risk of sudden cardiac death.
D. Avoiding competitive recreational sports is critical for clients with arrhythmogenic cardiomyopathy, as these activities can increase the risk of sudden cardiac events due to physical exertion.

A. Black cohosh B. Echinacea C. Saw palmetto D. Ginkgo biloba

Correct Answer is D

Explanation

A. Black cohosh is typically used for menopausal symptoms and does not have a known effect on walking distance in peripheral arterial disease.
B. Echinacea is primarily used to boost the immune system and treat colds, not for vascular conditions.
C. Saw palmetto is commonly used for benign prostatic hyperplasia (BPH) and does not have evidence supporting its use for peripheral arterial disease.
D. Ginkgo biloba has been shown to improve blood flow and may help increase pain-free walking distance in clients with peripheral arterial disease by enhancing peripheral circulation.

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A home health nurse is collecting data from 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

Naxlex Comprehensive Predictor Exams

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