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: Skin becomes more vulnerable to sun damage is true because as the skin ages, it loses its elasticity and ability to repair itself from the harmful effects of ultraviolet (UV) radiation. Sun damage can cause wrinkles, age spots, and skin cancer. The nurse would advise the older adult person to protect their skin from the sun by wearing sunscreen, hats, and clothing that covers the skin.
Choice B reason: Sweat gland activity increases is false because as the skin ages, it produces less sweat and oil, which can make the skin dry and prone to itching. The nurse would advise the older adult person to moisturize their skin regularly and avoid hot showers or baths that can dry out the skin.
Choice C reason: Skin becomes darker in unexposed areas is false because as the skin ages, it produces less melanin, the pigment that gives the skin its color. This can make the skin lighter and more sensitive to sunburn. The nurse would advise the older adult person to check their skin for any changes in color, shape, or size of moles or spots that could indicate skin cancer.
Choice D reason: Generous amounts of soap should be used for cleansing is false because as the skin ages, it becomes thinner and more fragile, and can be irritated by harsh chemicals or fragrances. The nurse would advise the older adult person to use mild, unscented soap and water for cleansing, and to pat the skin dry gently.
Correct Answer is B
Explanation
Choice A reason: Risk for injury is a potential nursing diagnosis for a client who recently experienced a stroke, but it is not the priority. Risk for injury is related to the possible complications of stroke, such as hemiparesis, hemiplegia, dysphagia, or sensory deficits, that may increase the risk of falls, aspiration, or pressure ulcers. However, these complications are secondary to the primary problem of altered cerebral perfusion, which is the cause of stroke.
Choice B reason: Altered cerebral perfusion is the priority nursing diagnosis for a client who recently experienced a stroke, because it is the most urgent and life-threatening problem. Altered cerebral perfusion is defined as a decrease in blood flow to the brain, which can result in ischemia, infarction, or hemorrhage of the brain tissue. This can lead to irreversible neurological damage, disability, or death. Therefore, the nurse should focus on restoring and maintaining adequate cerebral perfusion as the first priority.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today