A patient diagnosed with Heart Failure would like the nurse to explain what the diagnosis means.
How will the nurse explain heart failure?
The heart muscle cannot pump effectively, causing a backup of blood.
Increased protein leads to reduced oncotic pressure and inability to pull the fluid into the system.
The hydrostatic pressure pushing fluids out of the capillary is lower than the oncotic pressure.
The decrease in venous pressure from the backup of blood increases hydrostatic pressure.
The Correct Answer is A
Choice A rationale
Heart failure occurs when the heart muscle cannot pump blood effectively, leading to a backup of blood and fluid buildup in the lungs, legs, and other parts of the body. This explanation is accurate and helps the patient understand the nature of their condition.
Choice B rationale
Reduced oncotic pressure due to increased protein levels is not a primary factor in heart failure. Heart failure is related to the heart’s inability to pump effectively, not protein levels affecting oncotic pressure.
Choice C rationale
Hydrostatic pressure pushing fluids out of the capillaries is not directly related to heart failure. In heart failure, the issue lies in the heart’s inability to pump blood efficiently, leading to fluid buildup rather than fluid being pushed out of capillaries.
Choice D rationale
The decrease in venous pressure from the backup of blood does not cause heart failure. Heart failure results from the heart’s inability to pump blood effectively, leading to increased pressure and fluid buildup, not a decrease in venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Asking the patient what time of day the medication is taken can help identify if taking it at a different time might alleviate sleep disturbances. SSRIs like sertraline can cause insomnia if taken later in the day.
Choice B rationale
Recommending a weekly dosage is inappropriate and could potentially disrupt the therapeutic effect. SSRIs should be taken daily, as prescribed.
Choice C rationale
Counseling the patient to take the medication at bedtime could worsen sleep disturbances, as sertraline may cause insomnia in some individuals. Timing should be adjusted based on patient response.
Choice D rationale
Suggesting a lower dose without consulting the provider may not address the issue effectively and could reduce the efficacy of the medication. Dosage adjustments should be made based on clinical assessment and provider recommendation.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Analyzing data collected is part of the assessment phase, not the intervention phase.
Choice B rationale
Collecting a nursing history is part of the assessment phase of the nursing process, not the intervention phase.
Choice C rationale
Determining medication effectiveness is a critical aspect of the intervention phase, as it assesses the therapeutic outcomes of the administered drugs.
Choice D rationale
Documenting the medication is a key action in the intervention phase to ensure accurate and up-to-date patient records and safe administration.
Choice E rationale
Administering the medication is a direct intervention related to drug therapy and is part of the intervention phase.
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