A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

Cardiac monitoring

Daily weight measurement

Blood pressure monitoring

Urine output measurement

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Cardiac monitoring involves the continuous observation of the heart’s electrical activity, typically using an electrocardiogram (ECG). While cardiac monitoring is essential for detecting arrhythmias and other cardiac events, it does not directly measure fluid retention. Fluid retention in CHF patients can lead to symptoms such as edema and weight gain, which are not directly assessed through cardiac monitoring.

Choice B Reason:

Daily weight measurement is a reliable and practical method for assessing fluid retention in clients with congestive heart failure. Fluid retention leads to an increase in body weight, and monitoring daily weight changes can help detect fluid accumulation early. A sudden weight gain of more than 2-3 pounds in a day or 5 pounds in a week is a significant indicator of fluid retention and worsening heart failure. This method is non-invasive, easy to perform, and provides valuable information for managing CHF.

Choice C Reason:

Blood pressure monitoring is crucial for managing clients with CHF, as hypertension can exacerbate heart failure. However, blood pressure readings alone do not provide a direct measure of fluid retention. While fluid overload can affect blood pressure, it is not a specific or sensitive indicator of fluid status. Blood pressure monitoring should be used in conjunction with other assessment tools to manage CHF effectively.

Choice D Reason:

Urine output measurement is an important parameter for assessing kidney function and fluid balance. In clients with CHF, reduced urine output can indicate worsening heart failure and fluid retention. However, urine output alone may not provide a complete picture of fluid status, especially if the client is on diuretic therapy. Daily weight measurement remains a more direct and reliable method for assessing fluid retention in CHF patients.

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Correct Answer is B

Explanation

Choice A Reason:

Prolonging the life of a client is not the primary focus of palliative care. While palliative care can sometimes extend life by improving overall well-being and reducing stress, its main goal is to enhance the quality of life by managing symptoms and providing comfort12. Palliative care is not primarily aimed at life extension but rather at ensuring that patients live as well as possible despite their illness.

Choice B Reason:

Controlling symptoms and providing comfort is the core focus of palliative care. This type of care aims to alleviate pain and other distressing symptoms, such as nausea, shortness of breath, and fatigue12. Palliative care also addresses emotional, social, and spiritual needs, helping patients and their families cope with the challenges of serious illness. By focusing on comfort and quality of life, palliative care supports patients in living as fully as possible.

Choice C Reason:

Replacing other treatments for an illness is not the focus of palliative care. Palliative care is designed to complement, not replace, other medical treatments12. It can be provided alongside curative or life-prolonging treatments, offering additional support to manage symptoms and improve quality of life. The goal is to provide a holistic approach to care that addresses all aspects of a patient’s well-being.

Choice D Reason:

Curing a serious illness is not the aim of palliative care. Palliative care is appropriate for patients at any stage of a serious illness, whether or not a cure is possible12. Its primary focus is on symptom management, comfort, and quality of life, rather than on curing the illness. This approach helps patients and their families navigate the complexities of serious health conditions with greater ease and support.

A. Use good body mechanics. B. Maintain proper posture. C. Use assistive devices. D. Stay physically fit.

Correct Answer is A

Explanation

Choice A Reason:

Use good body mechanics is correct. Good body mechanics involve using the body in an efficient and careful way to prevent injury. This includes bending at the knees instead of the waist, keeping the back straight, and using the legs to lift heavy objects. Proper body mechanics reduce the strain on the back and joints, preventing injuries.

Choice B Reason:

Maintain proper posture is also important but is part of using good body mechanics. Proper posture involves keeping the spine in a neutral position, avoiding slouching, and ensuring that the head is aligned with the spine. This helps distribute weight evenly and reduces the risk of injury.

Choice C Reason:

Use assistive devices is correct. Assistive devices such as transfer boards, mechanical lifts, and gait belts can help reduce the physical strain on nurses when moving or lifting patients. These devices are designed to make tasks safer and easier, thereby minimizing the risk of back and joint injuries.

Choice D Reason:

Stay physically fit is also important. Physical fitness helps maintain muscle strength, flexibility, and endurance, which are crucial for performing physically demanding tasks. Regular exercise can help prevent injuries by improving overall body mechanics and reducing fatigue.

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A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

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