A nurse is assessing a newly admitted client with a history of chronic heart failure who has new onset confusion after forgetting to take his medications for a few days. The client has peripheral edema, mild shortness of breath, and bilateral crackles in the lung bases. Which of the following assessments is the priority for the nurse?
Capillary refill and depth of peripheral edema
Abdominal sounds and obtain a BNP level
Neurological status and obtain electrolyte levels
Skin turgor and measure intake & output (I&O)
The Correct Answer is C
A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.
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Related Questions
Correct Answer is D
Explanation
A. Hypomagnesemia: While hypomagnesemia can cause weakness and other symptoms, it is less commonly associated with fluid volume deficit compared to other imbalances in this context.
B. Hyperphosphatemia: Hyperphosphatemia is typically associated with renal failure or specific conditions, but it does not directly correlate with fluid volume deficit or the symptoms described.
C. Hypokalemia: Hypokalemia can cause weakness and abdominal pain, but it is less likely to be directly associated with the type of symptoms presented in this oncology context.
D. Hypercalcemia: This is the correct choice. Hypercalcemia, often associated with bone metastases, can lead to weakness, abdominal pain, and dehydration, as well as contribute to fluid volume deficit through increased urinary calcium excretion and renal effects.
Correct Answer is A
Explanation
A. Steak and scrambled eggs: Steak and scrambled eggs are excellent sources of heme iron, which is highly bioavailable and easily absorbed by the body. This choice reflects a good understanding of dietary sources rich in iron.
B. Cornmeal muffin and orange juice: While orange juice can enhance iron absorption due to its vitamin C content, cornmeal muffins are not a significant source of iron. This option does not indicate a strong understanding of iron-rich foods.
C. Cantaloupe and cottage cheese: Both cantaloupe and cottage cheese are low in iron content. This menu choice does not reflect an understanding of the best dietary sources of iron.
D. Strawberry pancakes and coffee: Strawberries have some iron, but not in significant amounts, and coffee can inhibit iron absorption due to its polyphenol content. This choice does not indicate an understanding of iron-rich foods.
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