A nurse is assisting with the care of a client in an outpatient provider's office.
The nurse should identify that the client is at risk of developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The nurse should identify that the client is at risk of developing heart failure and may require further assessment and intervention.
Heart failure is suggested by the progressive decline in vital signs and laboratory results, such as increasing BUN and creatinine levels, which indicate worsening kidney function and can contribute to heart failure. The client’s fatigue, weakness, bilateral edema, and crackles in the lungs are clinical signs consistent with heart failure. The dry, flaky skin and coarse, thinning hair also reflect systemic issues that could be associated with heart failure and poor nutritional status.
The nurse should focus on further assessment to evaluate the severity of heart failure and intervention to manage symptoms, potentially including medication adjustments, fluid management, and additional diagnostic testing. These steps are crucial to addressing the client’s deteriorating condition and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. While monitoring dietary potassium might be relevant for some clients on certain medications, it is not the primary action for addressing syncope related to enalapril.
B. Incorrect. Withholding the medication based solely on pulse rate is not an appropriate action.
The nurse should provide guidance on appropriate management.
C. Incorrect. Decreasing daily fluid intake is not likely to address the syncope related to enalapril.
D. Correct. Enalapril is an ACE inhibitor, and syncope can be a side effect due to changes in blood pressure. Advising the client to rise slowly from a sitting position can help prevent sudden drops in blood pressure and decrease the risk of syncope.
Correct Answer is C
Explanation
The correct answer is choice c. “I am thankful I am done having children.”
Choice A rationale: This statement is incorrect because a vaginal hysterectomy involves the removal of the uterus, which means the client will no longer have menstrual periods.
Choice B rationale: This statement is incorrect because even after a hysterectomy, regular gynecological examinations are still necessary to monitor the health of the remaining reproductive organs and overall health.
Choice C rationale: This statement indicates that the client understands the implications of the surgery, specifically that they will no longer be able to have children, which is a key aspect of informed consent for a hysterectomy.
Choice D rationale: This statement is incorrect because a vaginal hysterectomy does not involve an abdominal incision, so there will not be a large scar on the stomach. The procedure is performed through the vagina.
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