A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider’s office.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct condition
Heart failure is indicated by dyspnea, orthopnea, fatigue, peripheral edema, and elevated BNP >100 pg/mL (client's is 352 pg/mL).
Cardiomegaly and pleural congestion on chest x-ray further confirm fluid overload consistent with heart failure.
Atrial fibrillation, irregular pulse, and furosemide administration support cardiovascular compromise.
The use of accessory muscles and need for oxygen show decreased pulmonary function due to fluid buildup.
Absence of infection or anemia and normal glucose levels rule out other causes.

Rationale for correct actions
Elevating the head of the bed reduces venous return and pulmonary congestion, easing respiratory effort in heart failure.
It enhances diaphragmatic expansion, improving ventilation and oxygenation.
This non-invasive measure provides immediate symptom relief in fluid-overloaded patients.
Encouraging a low-sodium diet limits fluid retention by reducing intravascular volume through osmotic balance.
It helps decrease preload and afterload, improving cardiac efficiency.
Long-term dietary sodium restriction is essential to minimize exacerbation of fluid overload in chronic heart failure.

Rationale for correct parameters
Monitoring urinary output evaluates furosemide effectiveness and fluid status.
It reflects renal perfusion and response to diuretics in volume-overloaded states.
Oliguria may indicate worsening heart failure or renal dysfunction.
Blood pressure monitoring assesses hemodynamic stability and effectiveness of medications like carvedilol.
Hypertension increases afterload, exacerbating heart failure.
Hypotension may signal over-diuresis or digoxin toxicity.

Rationale for incorrect conditions
Anemia is unlikely due to normal hemoglobin (14.2 g/dL; normal 14–18 g/dL).
There is no evidence of blood loss, pallor, or tachycardia secondary to low oxygen-carrying capacity.
Type 2 diabetes is stable; HbA1c is 6.2% (target <7%) and glucose is normal at 102 mg/dL.
No symptoms of hypo/hyperglycemia are reported.
Urinary tract infection is excluded by normal WBC count (6,000/mm³), afebrile status, and clear urinalysis.

Rationale for incorrect actions
Teaching hyperglycemia signs is diabetes-specific, not acute heart failure management.
Iron-rich foods are unnecessary with normal hemoglobin and no anemia.
Foot sensation assessment pertains to diabetic neuropathy, not cardiopulmonary care.

Rationale for incorrect parameters
WBC count is normal and not relevant to non-infectious heart failure.
Fingerstick glucose is stable and not related to current symptoms.
Hemoglobin is within range and not a focus in fluid overload without anemia.

Take home points

Heart failure presents with fluid retention signs, elevated BNP, and pulmonary congestion.
Differentiate heart failure from anemia by evaluating hemoglobin and clinical signs.
Avoid focusing on diabetes in stable patients without hyper/hypoglycemic symptoms.
Management priorities in heart failure include fluid control, oxygenation, and dietary sodium restriction.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D","E","F"]

Explanation

Choice A rationale

A family history of breast cancer, particularly in first-degree relatives, significantly increases an individual's risk due to the potential inheritance of genetic mutations, such as BRCA1 and BRCA2. These genes play crucial roles in DNA repair, and their mutation impairs this function, leading to uncontrolled cell proliferation and increased cancer susceptibility.

Choice B rationale

Increased alcohol consumption is a known risk factor for breast cancer. Alcohol metabolism produces acetaldehyde, a genotoxic compound, and also elevates estrogen levels. Both mechanisms contribute to cellular DNA damage and promote cell proliferation, thereby increasing the risk of malignant transformation in mammary tissue.

Choice C rationale

Breastfeeding is scientifically recognized as a protective factor against breast cancer. The physiological changes during lactation, including terminal differentiation of mammary epithelial cells and reduced lifetime exposure to estrogen, decrease the risk of malignant transformation. Longer durations of breastfeeding correlate with greater risk reduction.

Choice D rationale

Early menarche, defined as the onset of menstruation before age 12, increases a woman's lifetime exposure to estrogen. Estrogen is a key hormone in breast tissue development and proliferation. Prolonged exposure to higher estrogen levels throughout reproductive life is associated with an elevated risk of developing breast cancer due to increased cell division.

Choice E rationale

The use of oral contraceptives has been linked to a slightly increased risk of breast cancer, particularly current or recent use. These contraceptives contain exogenous hormones, primarily estrogen and progestin, which can influence mammary gland proliferation. The risk generally decreases over time after discontinuation of oral contraceptive use.

Choice F rationale

Late menopause, occurring after age 55, extends the duration of a woman's exposure to endogenous estrogen and progesterone. These hormones stimulate breast cell growth and division. A longer period of ovarian hormone activity means more cumulative cell divisions and greater opportunity for genetic mutations, thus increasing breast cancer risk.

A. CBC. B. PPD test. C. Chest x-ray. D. HIV test.

Correct Answer is D

Explanation

Choice A rationale

A complete blood count (CBC) analyzes cellular components of blood, including red and white blood cells and platelets. While a CBC can reveal general health status and signs of infection or anemia, it does not directly diagnose the underlying cause of unexplained weight loss and fatigue in this context, especially given the historical negative HIV status.

Choice B rationale

A purified protein derivative (PPD) test screens for tuberculosis infection by detecting an immune response to mycobacterial antigens. While unexplained weight loss can be a symptom of tuberculosis, the initial presentation with nausea and exhaustion, coupled with negative HIV status 8 months prior, suggests a broader differential diagnosis requiring a more comprehensive initial screening.

Choice C rationale

A chest x-ray provides an image of the heart, lungs, and blood vessels, primarily used to diagnose respiratory conditions like pneumonia or tuberculosis. While lung pathology can cause fatigue and weight loss, a chest x-ray is a focused diagnostic tool and may not be the most appropriate initial screening test for the client's constellation of symptoms.

Choice D rationale

Given the client's symptoms of nausea, exhaustion, and significant unplanned weight loss, a repeat HIV test is crucial. Despite a negative test 8 months prior, these symptoms are highly suggestive of a retroviral syndrome or progression to AIDS, which can manifest with constitutional symptoms and opportunistic infections leading to profound weight loss.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing a lecture about cancer prevention strategies for clients seeking to engage in health promotion. The nurse should include which of the following risk factors for the development of breast cancer? (Select all that apply)

Correct Answer is ["A","B","D","E","F"]

Explanation

A nurse is caring for a client with reported nausea, exhaustion, and unplanned weight loss of 24 pounds over 3 months. The client's lab results from 8 months ago indicate negative HIV and hepatitis status. The nurse should anticipate which of the following healthcare provider orders?

Correct Answer is D

Explanation

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