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 A
Explanation
Choice A reason: Improper assistive device use contributes to older adult falls is a true statement, as it is supported by evidence from web search results. According to the Age Space guide to assistive technology for the elderly, "it is important to ensure that the device is used correctly and safely, as improper use can increase the risk of falls and injuries." Similarly, according to the AAFP article on mobility assistive device use in older adults, "improper use of assistive devices can lead to falls, injuries, and decreased mobility."
Choice B reason: Older adults save money by adopting assistive devices from their friends is not a true statement, as it is not recommended by experts. According to the AAFP article on mobility assistive device use in older adults, "borrowing devices from friends or family members is not advised because devices may not be properly fitted or maintained, and may not meet the patient's needs."
Choice C reason: A walker can be used when climbing stairs is not a true statement, as it is not safe or feasible. According to the NICHD article on types of assistive devices and their use, "walkers are not designed for use on stairs or escalators."
Choice D reason: Cane tips should be smooth is not a true statement, as it is contrary to the best practice. According to the AAFP article on mobility assistive device use in older adults, "cane tips should have a nonskid surface to prevent slipping."
Choice E reason: None of the above is not the correct answer, as there is one choice that is a true statement about assistive devices to aid older adults with impaired mobility.
Correct Answer is A
Explanation
Choice A reason: Awakens with periodic left-foot numbness is an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it may indicate peripheral neuropathy, which is a common complication of diabetes. Peripheral neuropathy is a nerve damage that affects the feet and legs, causing numbness, tingling, pain, or weakness. Peripheral neuropathy can increase the risk of foot ulcers, infections, and amputations. The nurse should educate the older adult about the importance of regular foot care, blood sugar control, and medication adherence.
Choice B reason: Enjoys spicy food more than bland food is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a personal preference that does not affect the blood glucose levels. However, the nurse should advise the older adult to limit the intake of salt, fat, and sugar, and to follow a balanced and nutritious diet that meets their needs and preferences.
Choice C reason: Has difficulty hearing conversations in crowded rooms is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a common age-related change that does not affect the blood glucose levels. However, the nurse should assess the older adult's hearing ability and provide appropriate aids and strategies to enhance their communication and socialization.
Choice D reason: Requires reading glasses at 2.0 strength is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a common age-related change that does not affect the blood glucose levels. However, the nurse should assess the older adult's vision and provide appropriate aids and strategies to improve their safety and quality of life.
Choice E reason: None of the above is not the correct answer, as there is one choice that is an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar.
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