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 B
Explanation
A. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
B. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Submerging the feet in ice water is not recommended as it can cause vasoconstriction and shivering, which may increase the body temperature. Instead, tepid sponging and providing a cool environment can be beneficial.
D. Covering the adolescent with a thermal blanket would retain body heat and exacerbate hyperthermia, counteracting efforts to lower the body temperature.
Correct Answer is B
Explanation
A: While social workers can assist with many aspects of care, they may not always be able to provide legal representation or assistance.
B: While legal representation can be helpful, advance directives can be valid and legally binding documents even without it.
C: Verbal agreements are generally not sufficient for advance directives; written documentation is typically required.
D: While medical care can be initiated regardless of advance directives, it's important to inform the client that they can create directives without immediate legal assistance.
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