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 A

Explanation

A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), confirming the diagnosis of myasthenia gravis.
B. A "pill-rolling" tremor is associated with Parkinson's disease, not myasthenia gravis, and is not relevant to this test.
C. While muscle electrical activity can be assessed in other tests, the Tensilon test specifically evaluates muscle strength changes, not electrical charge intensity.
D. No change in muscle strength would suggest a negative result for myasthenia gravis, indicating that the test did not confirm the diagnosis.

A. "I will use a thermometer to check the temperature of my bath water." B. "I will wear stockings with elastic tops." C. "I will not go barefoot." D. "I will avoid crossing my legs at the knees."

Correct Answer is B

Explanation

A. Using a thermometer to check the temperature of bath water is a safe practice that helps prevent burns, which is important for clients with PVD who may have reduced sensation.
B. Wearing stockings with elastic tops can restrict blood flow and is generally not recommended for clients with PVD; clients should use non-restrictive stockings instead.
C. Not going barefoot is a good practice to prevent injuries and ulcers, which are risks for clients with PVD.
D. Avoiding crossing the legs is advisable as it helps maintain adequate blood flow and reduces the risk of circulation problems.

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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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Correct Answer is A

Explanation

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Correct Answer is B

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