The nurse is evaluating the outcome of the treatment goals for a client with heart failure.
Which of the following would be the best query for the nurse to ask?

How has your energy level been?

How many pillows are you using to sleep?

Have you been exercising regularly?

Have you had any chest pain?.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Assessing energy levels provides indirect information about cardiac output but lacks specificity regarding fluid overload or pulmonary congestion, which are key indicators of heart failure exacerbation. It is a relevant question but not the best for evaluating treatment outcomes.

Choice B rationale

Asking about pillow use evaluates orthopnea, a common symptom of heart failure due to fluid buildup in the lungs when lying flat. It provides a direct assessment of fluid status and the effectiveness of heart failure management, making it the best question.

Choice C rationale

Exercising regularly is an important lifestyle aspect for heart failure patients but does not directly assess the status of symptoms such as fluid overload or cardiac function. Thus, it is not the most critical outcome measure.

Choice D rationale

Chest pain can indicate ischemia or worsening cardiac function but is not specific to fluid status or pulmonary congestion in heart failure. Therefore, it is a relevant but less optimal question for evaluating treatment goals.

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Correct Answer is C

Explanation

Choice A rationale

Constant erythema and warmth in the legs are indicative of venous insufficiency due to stagnant blood flow. PAD typically presents with cool, pale extremities as a result of reduced arterial perfusion.

Choice B rationale

Discomfort typically worsens when legs are elevated in PAD because elevation further impairs blood flow, causing ischemic pain. Relief is more commonly achieved when the legs are in a dependent position, aiding perfusion.

Choice C rationale

Pain during exercise, termed intermittent claudication, occurs due to insufficient oxygen delivery to muscles. Rest alleviates symptoms as oxygen demand decreases. This hallmark feature distinguishes PAD from other circulatory disorders.

Choice D rationale

Peripheral pulses in PAD are generally diminished or absent, reflecting compromised arterial blood flow. Bounding pulses would suggest conditions such as aortic regurgitation or hyperdynamic states, not PAD.

A. Over-the-counter Sudafed should not be taken while I am taking this medication. B. I will stop taking the medication if I have any signs or symptoms of infection. C. I will not combine this medication with any type of antidepressant medications. D. Retention of urine can occur while taking the medication and should be reported.

Correct Answer is A

Explanation

Choice A rationale

Over-the-counter Sudafed contains pseudoephedrine, which can cause urinary retention by stimulating alpha-adrenergic receptors, exacerbating symptoms treated by oxybutynin. Avoiding this combination reduces the risk of adverse effects, indicating correct client understanding.

Choice B rationale

Stopping the medication due to signs of infection is incorrect. Oxybutynin addresses bladder muscle control and is not associated with infection management. Reporting adverse effects is required, but discontinuation must follow medical advice.

Choice C rationale

Antidepressants like tricyclics have anticholinergic effects similar to oxybutynin, potentially increasing adverse effects. However, abrupt contraindication is incorrect unless specified by a healthcare provider, indicating a misunderstanding.

Choice D rationale

Urinary retention is a known side effect of oxybutynin. Reporting symptoms is correct, but this statement lacks broader understanding of the medication’s use and side effect profile. .

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The nurse is evaluating the outcome of the treatment goals for a client with heart failure.Which of the following would be the best query for the nurse to ask?

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The nurse is evaluating the outcome of the treatment goals for a client with heart failure.
Which of the following would be the best query for the nurse to ask?