An older adult diagnosed with heart failure (HF) reports increasing dyspnea over 2 days. Which of the following should the nurse assess to help determine whether the client has adhered to prescribed therapy? (Select all that apply.)
Determine coughing frequency.
Check for peripheral edema.
Auscultate the lungs bilaterally.
Assess diet over the last 48 hours.
Compare current weight to baseline.
Correct Answer : B,C,D,E
Choice A reason: Determining coughing frequency is not a reliable way to assess whether the client has adhered to prescribed therapy, as coughing can have various causes and may not be related to heart failure or its treatment.
Choice B reason: Checking for peripheral edema is a useful way to assess whether the client has adhered to prescribed therapy, as peripheral edema is a common sign of fluid retention and worsening heart failure. If the client has been taking diuretics as prescribed, the edema should be reduced or absent.
Choice C reason: Auscultating the lungs bilaterally is a helpful way to assess whether the client has adhered to prescribed therapy, as lung sounds can indicate the presence or absence of pulmonary congestion and crackles, which are signs of fluid overload and worsening heart failure. If the client has been taking medications to improve cardiac function and reduce fluid volume as prescribed, the lungs should be clear or improved.
Choice D reason: Assessing diet over the last 48 hours is a relevant way to assess whether the client has adhered to prescribed therapy, as diet can affect fluid and sodium intake and retention, which can worsen heart failure. If the client has been following a low-sodium and fluid-restricted diet as prescribed, the risk of fluid overload and dyspnea should be lower.
Choice E reason: Comparing current weight to baseline is an important way to assess whether the client has adhered to prescribed therapy, as weight can reflect fluid status and changes in heart failure condition. If the client has been taking medications and following dietary recommendations as prescribed, the weight should be stable or decreased.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Drinking large amounts of alcohol can relieve symptoms of essential tremor is false because essential tremor is a different neurological disorder from PD, and alcohol can worsen PD symptoms or interact with medications.
Choice B reason: Motor tremors and slow movement accompany severe cognitive impairment is false because not all people with PD develop cognitive impairment, and the severity of motor and cognitive symptoms may not correlate.
Choice C reason: It is advised to take levodopa-carbidopa on an empty stomach is true because food, especially protein, can interfere with the absorption of levodopa-carbidopa, which is the main medication for PD.
Choice D reason: Lewy body dementia (LBD) is the most common form of dementia is false because Alzheimer's disease is the most common form of dementia, and LBD is a related but distinct condition that can affect some people with PD.
Correct Answer is A
Explanation
Choice A reason: This action is correct because the client is showing signs of a possible stroke, such as a severe headache and numbness in one side of the body. The nurse should call 9-11 immediately to get the client to the nearest hospital for urgent evaluation and treatment. The nurse should also monitor the client's vital signs, neurological status, and airway until help arrives.
Choice B reason: This action is incorrect because the client's headache and numbness are not likely to be caused by a migraine, but by a stroke. The nurse should not waste time asking about the client's history of headaches, but rather act quickly to get the client to the hospital. The nurse should also not assume that the client's symptoms are benign or familiar, but rather treat them as an emergency.
Choice C reason: This action is incorrect because the client's headache and numbness are not likely to be relieved by acetaminophen, but by a stroke. The nurse should not give the client any medication without a doctor's order, especially if the client has a history of TIA or stroke. The nurse should also not delay calling 9-11 by administering medication, as every minute counts in saving the client's brain cells.
Choice D reason: This action is incorrect because the client's headache and numbness are not likely to resolve within 24 hours, but by a stroke. The nurse should not reassure the client that the symptoms are temporary or harmless, but rather alert the client that they are signs of a serious condition. The nurse should also not delay calling 9-11 by providing false comfort, as the client's condition may worsen rapidly.
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