A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?
Tachycardia
Weight gain
Decreased thirst
Thready pulse
The Correct Answer is B
A. While tachycardia can occur in some cases of heart failure as a compensatory mechanism, it's not a universal manifestation.
B. In heart failure, weight gain is a common manifestation due to fluid retention caused by the heart's inability to pump blood effectively. This fluid buildup can lead to an increase in body weight, often evidenced by swelling in the legs, ankles, or abdomen.
C. Heart failure often leads to increased thirst due to fluid overload and decreased cardiac output, resulting in poor tissue perfusion.
D. A thready pulse may be present in heart failure due to decreased stroke volume, but it's not a primary manifestation typically associated with the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Splitting behavior, where the client views people and situations as either all good or all bad, is more characteristic of borderline personality disorder rather than histrionic personality disorder.
B. Emotional lability, characterized by rapid shifts in mood, is not a primary feature of histrionic personality disorder.
C. Unexpressive affect, or a lack of emotional expression, is not a typical feature of histrionic personality disorder, which often presents with exaggerated and dramatic emotional displays.
D. Self-centered behavior, including attention-seeking and dramatic behavior to gain approval or admiration from others, is a hallmark feature of histrionic personality disorder.

Correct Answer is ["B","C","D","G","H"]
Explanation
A. Contact precautions are not indicated based on the assessment findings provided.
Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.
C. a deep tendon reflex (DTR) grade of 3+ indicates a brisker than average response, which could be normal or potentially indicative of neurological hyperactivity. In such cases, creating a calming environment, which may include dimmed lighting, could potentially help in reducing stimuli that might exacerbate neurological excitability.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Preeclampsia can have adverse effects on fetal well-being, including intrauterine growth restriction and placental insufficiency. However, an external fetal monitoring provides a more accurate assessment of fetal heart rate patterns and allows for closer monitoring of fetal status in cases of maternal hypertension.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
