Exhibits

A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing: Heart failure.

The client presents with signs and symptoms consistent with heart failure, including cardiomegaly, bibasilar pleural congestion on chest x-ray, elevated BNP level, and vital signs indicating hypertension (BP 146/98 mm Hg), tachycardia (pulse rate 106/min), and tachypnea (respirations 24/min). Additionally, the client is prescribed medications commonly used to manage heart failure, such as digoxin and carvedilol, and is receiving a diuretic (furosemide) to address fluid overload associated with heart failure.
Action to Take:

Elevate the head of the bed: Elevating the head of the bed helps reduce venous return to the heart, decreasing preload and potentially alleviating symptoms of heart failure, such as dyspnea and orthopnea. It can also help prevent aspiration in clients with compromised cardiac function. Encourage intake of a low-sodium diet: A low-sodium diet is essential in managing heart failure as it helps reduce fluid retention and edema by decreasing fluid volume overload. Sodium restriction helps minimize fluid accumulation, which is crucial in preventing exacerbations of heart failure.
Parameter to Monitor:

Urinary output: Monitoring urinary output is important in assessing fluid balance and response to diuretic therapy in clients with heart failure. Decreased urinary output may indicate worsening heart failure or inadequate response to diuretic therapy, whereas increased output may suggest over-diuresis or improvement in heart failure symptoms.
Blood pressure: Monitoring blood pressure helps assess the effectiveness of treatment in managing heart failure and controlling hypertension, a common comorbidity. Hypertension can exacerbate heart failure, so monitoring blood pressure trends helps guide adjustments in medication therapy to achieve optimal blood pressure control and improve cardiac function.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. The client expresses feelings of frustration and difficulty coping with the chronic nature of RA: This indicates the client is struggling emotionally, which is common in chronic illnesses but does not directly reflect the effectiveness of the RA treatment regimen.

B. The client's C-reactive protein (CRP) levels have remained stable since the initiation of treatment: While stable CRP levels can indicate control of inflammation, they do not show improvement. Ideally, effective treatment would reduce CRP levels.

C. The client demonstrates improved range of motion in the affected joints during physical therapy sessions: Improved range of motion is a positive outcome, but it may not fully represent the overall effectiveness of the RA treatment, as joint damage can still progress.

D. The client's radiographic images show no progression of joint erosion compared to images from six months ago: This is the best indicator of effective RA management as it directly shows that the treatment is preventing further joint damage, which is a primary goal in managing RA.

A. "I will take my medication even if symptoms improve." B. "I will not have my hair dyed or relaxed unless I am in a period of remission." C. "I will sunbathe as often as possible to ensure I get enough vitamin D." D. "I will report any fever to my healthcare provider immediately."

Correct Answer is C

Explanation

A. "I will take my medication even if symptoms improve." This statement indicates understanding of the importance of medication compliance in managing SLE, as symptoms may improve but the disease may still be active.

B. "I will not have my hair dyed or relaxed unless I am in a period of remission." This statement shows awareness of avoiding potential triggers for disease flare-ups during active periods of SLE.

C. "I will sunbathe as often as possible to ensure I get enough vitamin D." Sun exposure can trigger or worsen SLE symptoms, and individuals with SLE are often advised to avoid excessive sun exposure and to use sun protection to minimize flare-ups.

D. "I will report any fever to my healthcare provider immediately." This statement demonstrates understanding of the importance of monitoring for signs of infection or disease flare-ups, which can be common in SLE.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). The nurse is assessing the client to determine the effectiveness of the current treatment regimen. Which finding would be the best indicator that the client's RA management is effective?

Correct Answer is D

Explanation

A nurse is caring for a client newly diagnosed with systemic lupus erythematosus (SLE). The nurse should recognize that which statement made by the client indicates the need for further teaching about the course and management of SLE?

Correct Answer is C

Explanation

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