An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

The client underwent a coronary artery bypass procedure in 1995.

The client had a colonoscopy performed for routine screening six months ago.

The client suffered from depression following the death of their spouse in 1999.

The client has been taking digoxin and furosemide daily since 1996.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While a coronary artery bypass procedure is a significant event in a patient’s medical history, it occurred in 1995, which is quite some time ago. Therefore, it may not be the most significant piece of data when planning this client’s care, given their current signs and symptoms.

Choice B rationale

A colonoscopy performed for routine screening six months ago is unlikely to be related to the client’s current symptoms of nausea, vomiting, and anorexia. Therefore, this choice is not the most significant piece of data when planning this client’s care.

Choice C rationale

Depression following the death of a spouse can significantly impact a person’s mental health. However, this event occurred in 1999, and while it may contribute to the client’s overall health status, it is not likely to be the most significant piece of data for planning care based on the client’s current symptoms.

Choice D rationale

The client has been taking digoxin and furosemide daily since 19962. Both of these medications are used to treat heart conditions. Digoxin strengthens the heart’s contractions, while furosemide is a diuretic that helps reduce fluid buildup. Given the client’s symptoms of nausea, vomiting, and anorexia, and their diagnosis of heart failure, this information is crucial. These symptoms could indicate a worsening of heart failure or side effects of the medication, which would significantly influence the plan of care.

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Correct Answer is D

Explanation

The correct answer is choice D: Initiate cardiopulmonary resuscitation (CPR).

Choice D rationale: The patient's respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and unresponsiveness indicate severe respiratory depression, which requires immediate intervention. CPR is the priority action to maintain circulation and oxygenation while awaiting further interventions.

Choice A rationale: Administering a second dose of naloxone may be necessary to counteract the effects of opioids. However, in this case, the patient's condition has severely deteriorated, and immediate resuscitation efforts take priority.

Choice B rationale: Preparing to assist with chest tube insertion is not the appropriate action in this situation. Chest tube insertion is used to treat conditions like pneumothorax or pleural effusion, which are not indicated in this scenario.

Choice C rationale: Determining the Glasgow Coma Scale score is useful for assessing the patient's level of consciousness but should not be the first action in this case. Ensuring adequate circulation and oxygenation through CPR is the priority.

A. Hypertension. B. Bronchitis. C. Diarrhea. D. Edema.

Correct Answer is A

Explanation

Choice A rationale

Hypertension is a condition that should be reported to the healthcare provider before administering phenylephrine. Phenylephrine is a decongestant used to relieve nasal discomfort caused by colds, allergies, and hay fever. It works by shrinking swollen nasal mucous membranes, which relieves nasal congestion. However, it can cause a rise in blood pressure, which could be dangerous for patients with hypertension.

Choice B rationale

Bronchitis is not a contraindication for phenylephrine. However, if the patient has a chronic respiratory condition like bronchitis, it’s always a good idea to discuss any new medications with the healthcare provider.

Choice C rationale

Diarrhea is not a contraindication for phenylephrine. Phenylephrine is not known to cause or worsen diarrhea.

Choice D rationale

Edema is not a contraindication for phenylephrine. However, if the patient has a history of heart disease or high blood pressure, which can sometimes cause edema, they should inform their healthcare provider.

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An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

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Correct Answer is D

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Correct Answer is A

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An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?