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","B","D","E"]
Explanation
Choice A reason: This is a correct answer because Alzheimer's disease affects the brain cells and causes them to degenerate and die. This leads to a gradual decline in cognitive abilities, such as memory, language, reasoning, and problem-solving.
Choice B reason: This is a correct answer because Alzheimer's disease interferes with the daily activities and routines of the affected person. They may experience a decline from their previous level of functioning, such as forgetting appointments, misplacing items, or getting lost.
Choice C reason: This is an incorrect answer because easily frustrated is not a specific outcome of the early stage of Alzheimer's disease. Although some people with Alzheimer's disease may become frustrated, irritated, or angry due to their cognitive impairment, this is not a universal or diagnostic symptom.
Choice D reason: This is a correct answer because Alzheimer's disease affects the short-term memory first, causing the person to forget recent events, conversations, or names. This is called mild memory loss, and it is one of the most common signs of the early stage of Alzheimer's disease.
Choice E reason: This is a correct answer because Alzheimer's disease affects the frontal lobe of the brain, which is responsible for executive functions, such as planning, organizing, decision-making, and judgement. This leads to impaired judgement, such as making poor financial choices, neglecting personal hygiene, or acting inappropriately.
Correct Answer is B
Explanation
Choice A reason: Wearing sturdy open-toed shoes is not a good idea for a person with diabetes, as it can expose the feet to injuries or infections that can be hard to heal. The nurse would advise the patient to wear well-fitting, closed-toe shoes that protect the feet and prevent blisters or ulcers.
Choice B reason: Monitoring blood glucose levels before and after a walk is a sensible instruction for a person with diabetes, as physical activity can lower blood glucose levels and affect the need for medication or insulin. The nurse would advise the patient to check his blood glucose levels before and after a walk, and adjust his food intake or medication accordingly.
Choice C reason: Omitting antidiabetic medication is a dangerous instruction for a person with diabetes, as it can cause hyperglycemia or high blood glucose levels that can lead to serious complications. The nurse would advise the patient to take his medication as prescribed, and consult his doctor if he needs to change his dosage.
Choice D reason: Preparing to administer insulin is an unnecessary instruction for a person with type 2 diabetes who is not on insulin therapy, as it can cause hypoglycemia or low blood glucose levels that can be life-threatening. The nurse would advise the patient to follow his doctor's recommendations on whether he needs insulin or not, and how to use it safely.
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