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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Hypernatremia, high blood sodium (normal 135–145 mEq/L), is indicated by the 158 mEq/L level. It results from water loss, causing dehydration (dry mucous membranes, low urine output) and neurological symptoms like confusion due to brain cell shrinkage. The symptoms and lab values align with hypernatremia in this elderly client.

Choice B reason: Hyperkalemia, high potassium (normal 3.5–5.0 mEq/L), is not indicated, as the potassium level is 4.8 mEq/L, within normal range. Hyperkalemia causes arrhythmias and muscle weakness, not confusion or dehydration signs. The primary issue is high sodium, pointing to hypernatremia, not potassium imbalance.

Choice C reason: Hyponatremia, low sodium, causes swelling and neurological symptoms like seizures. The client’s sodium of 158 mEq/L indicates hypernatremia, not hyponatremia. Dry mucous membranes and low urine output suggest water loss, not sodium dilution, making hyponatremia inconsistent with the clinical and lab findings.

Choice D reason: Hypokalemia, low potassium, causes muscle weakness and arrhythmias. The client’s potassium of 4.8 mEq/L is normal, and symptoms like confusion and dehydration point to hypernatremia, not potassium deficiency. The high sodium level and clinical presentation make hypokalemia an unlikely diagnosis in this case.

A. The nurse shows the best positions to hold the newborn while feeding B. The nurse explains the steps of warming a bottle C. The nurse has both parents demonstrate changing a diaper D. The nurse asks the clients their views on breastfeeding

Correct Answer is D

Explanation

Choice A reason: Showing positions for holding a newborn addresses the psychomotor domain, teaching physical skills. The affective domain involves emotions and attitudes, not physical techniques. This action helps parents learn how to feed but does not explore their feelings or beliefs, which is the focus of affective learning.

Choice B reason: Explaining bottle-warming steps targets the cognitive domain, focusing on knowledge and procedure. It does not address emotions or attitudes, which are central to the affective domain. This action provides technical understanding but does not engage the parents’ feelings or values about newborn care.

Choice C reason: Having parents demonstrate diaper changing is a psychomotor activity, emphasizing skill acquisition. The affective domain involves feelings and attitudes, not physical tasks. While this builds confidence, it does not directly address emotional engagement or beliefs, which are necessary for affective learning in this context.

Choice D reason: Asking about breastfeeding views targets the affective domain by exploring parents’ emotions, beliefs, and attitudes. This encourages reflection on personal values, fostering emotional engagement with newborn care. Addressing these feelings helps build confidence and commitment, aligning with affective learning goals in nursing education.

View Question and Answer

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

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 73-year-old hospitalized client demonstrates the following symptoms: dry mucous membranes, decreased urine output, confusion, a serum sodium of 158 mEq/L, a potassium of 4.8 mEq/L. The nurse recognizes that these symptoms are indicative of?

Correct Answer is A

Explanation

indicate the nurse is addressing the affective domain of learning?

Correct Answer is D

Explanation

A nurse in a community health clinic is assessing a client brought by their parents. Which of the following would be the highest priority nursing diagnosis?

A client continues to report nausea following surgery from the anesthesia. She has received an antiemetic, and the next dose is not due for another hour. What should the nurse do first?

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?

A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

A client states to the nurse, “I understand that I need a mastectomy, but I am worried about the pain and appearance afterwards.” When responding to the client, the nurse will need to address which domain?

A nurse is caring for a client with a new diagnosis of hyperthyroidism. Which symptom is most likely to be reported by this client?

A nurse is caring for a client with a suspected pulmonary embolism. Which diagnostic test is most likely to confirm this diagnosis?

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?