The nurse is assessing a client and asks which of the following questions to evaluate potential heart failure symptoms?

Have you been having swelling in your legs?

Have you been experiencing difficulty breathing?

Have you been experiencing chest pain?

Have you been experiencing heart palpitations?

Answer and Explanation

The Correct Answer is B

Choice A reason: Leg swelling (edema) is a symptom of heart failure due to fluid retention from poor cardiac output. However, it is less urgent than breathing difficulties, which indicate pulmonary edema, a life-threatening complication. Assessing breathing takes priority, as it directly affects oxygenation, a critical physiological need.

Choice B reason: Difficulty breathing (dyspnea) is a hallmark of heart failure, often due to pulmonary edema from fluid backup in the lungs. This compromises oxygenation, making it a life-threatening symptom requiring immediate assessment. The ABCD-E framework prioritizes breathing, making this the most critical question to evaluate heart failure severity.

Choice C reason: Chest pain may indicate angina or myocardial infarction, which can contribute to heart failure. However, it is less specific to heart failure than dyspnea, which directly signals pulmonary congestion. Breathing difficulties pose a more immediate threat, as they affect oxygenation, a priority in acute heart failure assessment.

Choice D reason: Heart palpitations may occur in heart failure due to arrhythmias but are less specific and urgent than dyspnea. Palpitations may indicate stress or other conditions, but breathing difficulties directly reflect pulmonary edema, a critical complication requiring immediate attention to ensure adequate oxygenation and prevent respiratory failure.

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Correct Answer is B

Explanation

Choice A reason: Instructing on walker movement addresses the psychomotor domain, focusing on physical skills. This does not tackle the client’s emotional disengagement or belief of being “too old.” Without addressing motivation, technical instructions may be ineffective, as the client’s psychological barrier prevents engagement, reducing the likelihood of successful learning and adoption.

Choice B reason: Describing quality-of-life benefits targets the affective domain, addressing emotions and attitudes. By emphasizing enhanced independence, safety, and mobility, the nurse can counter the client’s defeatist mindset. This approach fosters motivation, making the client more receptive to learning walker use, as it connects the intervention to personal, meaningful outcomes.

Choice C reason: Explaining walker support for lower extremities focuses on the cognitive domain, providing technical knowledge. While informative, it does not address the client’s emotional disengagement. Without motivating the client by linking the walker to personal benefits, this approach may fail to overcome their resistance, as it lacks an emotional or motivational component.

Choice D reason: Discussing the rationale for walker use targets the cognitive domain, explaining its purpose. While this may enhance understanding, it does not address the client’s emotional barrier or lack of motivation. Without engaging the client’s feelings or highlighting personal benefits, the rationale alone is unlikely to inspire willingness to learn or use the walker.

A. A client who is scheduled for discharge and has become febrile this morning B. A client who has early dementia and awoke confused to their location this morning C. A client who has pneumonia and has developed wheezing D. A client who is postoperative and has a urine output of 50 mL for the past 4 hours

Correct Answer is C

Explanation

Choice A reason: Fever in a discharge-ready client suggests a new infection, which is concerning but not immediately life-threatening. The ABCD-E framework prioritizes airway and breathing issues. While fever requires evaluation, it is less urgent than respiratory distress, as it does not acutely compromise vital functions like oxygenation.

Choice B reason: Confusion in early dementia is common and concerning but not an immediate threat to life. The ABCD-E framework prioritizes airway, breathing, and circulation. Confusion may indicate worsening dementia or another issue, but it is less urgent than a client with acute respiratory distress, like wheezing.

Choice C reason: Wheezing in a pneumonia client indicates airway obstruction or bronchospasm, compromising breathing (B in ABCD-E). This is a life-threatening emergency requiring immediate intervention to ensure oxygenation. Respiratory distress takes priority over fever, confusion, or low urine output, as it directly affects a vital function critical for survival.

Choice D reason: Low urine output (50 mL/4 hours) in a postoperative client suggests possible hypovolemia or renal issues, affecting circulation (C in ABCD-E). While serious, it is less urgent than airway or breathing problems. Respiratory distress, like wheezing, takes precedence, as it poses an immediate threat to life.

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The nurse is assessing a client and asks which of the following questions to evaluate potential heart failure symptoms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with an older adult and educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears disengaged and states, “I’m just too old to learn.” What would be most appropriate for the nurse to do to motivate this client?

Correct Answer is B

Explanation

A nurse is receiving report on a group of clients. Using the ABCD-E priority framework, which of the following clients should the nurse see first?

Correct Answer is C

Explanation

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