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 B
Explanation
Choice A reason: Fecal impaction is not the most common gastrointestinal complaint, as it is a condition that occurs when hardened stool accumulates in the rectum and cannot be expelled. Fecal impaction may cause abdominal pain, bloating, nausea, and loss of appetite. Fecal impaction is more common in older adults, people with low-fiber diets, or people who take certain medications, such as opioids or anticholinergics.
Choice B reason: Diarrhea is the most common gastrointestinal complaint, as it is a condition that occurs when the stool is loose, watery, and frequent. Diarrhea may cause dehydration, electrolyte imbalance, and malabsorption. Diarrhea can be caused by various factors, such as infections, food intolerance, medications, or irritable bowel syndrome.
Choice C reason: Constipation is not the most common gastrointestinal complaint, as it is a condition that occurs when the stool is hard, dry, and infrequent. Constipation may cause straining, pain, bleeding, and hemorrhoids. Constipation can be caused by various factors, such as lack of fluids, fiber, or exercise, or certain medications, such as antacids or iron supplements.
Choice D reason: Hemorrhoids are not the most common gastrointestinal complaint, as they are swollen veins in the lower rectum or anus that may cause itching, pain, or bleeding. Hemorrhoids can be caused by various factors, such as constipation, straining, pregnancy, or aging.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the most common gastrointestinal complaint.
Correct Answer is B
Explanation
Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.
Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.
Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.
Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.
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