The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first?
Heart sounds
Chest pain
Bilateral lung sounds
Mood and affect
The Correct Answer is C
c) Bilateral lung sounds.
Explanation:
When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.
While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admited with complications of left-sided heart failure.
The other options are considered incorrect because they are not the priority assessments when admitting a client with complications of left-sided heart failure.
Option a) Heart sounds: While assessing heart sounds is important in evaluating cardiac function, the priority in this scenario is to assess for pulmonary congestion and impaired gas exchange. Assessing bilateral lung sounds allows the practical nurse to gather immediate information about the client's respiratory status and the presence of fluid in the lungs.
Option b) Chest pain: Chest pain is a significant symptom that should be assessed promptly, as it could indicate various cardiac or respiratory conditions. However, in this specific scenario, the priority is to assess for signs of pulmonary congestion, which can have a more immediate impact on the client's respiratory function.
Option d) Mood and affect: Assessing the client's mood and affect is important for a comprehensive assessment of their emotional well-being. However, when admitting a client with complications of left- sided heart failure, the priority is to assess their physical condition, particularly the respiratory status, to address any immediate concerns related to pulmonary congestion and impaired gas exchange.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Planning medication doses to occur before meals is a good suggestion to improve this client's nutritional status because it can enhance the client's muscle strength and coordination for chewing and swallowing, which are often impaired by myasthenia gravis.
Choice B reason: Restricting drinking fluids before and during meals is not a good suggestion to improve this client's nutritional status because it can increase the risk of dehydration and constipation, which can worsen the client's condition and appetitE.
Choice C reason: Increasing the amount of fat and carbohydrates in meals is not a good suggestion to improve this client's nutritional status because it can lead to weight gain, hyperglycemia, and cardiovascular problems, which can complicate the management of myasthenia gravis.
Choice D reason: Eating three large meals per day is not a good suggestion to improve this client's nutritional status because it can cause fatigue, bloating, and aspiration, which can affect the client's ability and willingness to eat. The client should eat small, frequent meals that are easy to chew and swallow.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Epidemiology interprets legislation in the community is not a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology does not deal with legal issues, but rather with scientific methods and evidencE.
Choice B reason: Epidemiology relates to the health status of a population is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology measures and monitors the frequency, distribution, and trends of diseases and health indicators in a population.
Choice C reason: Epidemiology analyzes and examines the root causes of health outcomes is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology identifies and investigates the factors and interactions that influence the occurrence and prevention of diseases and health conditions.
Choice D reason: Epidemiology evaluates the effectiveness of nursing interventions is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology designs and conducts studies to assess the impact and outcomes of nursing programs, policies, and practices on population healtH.
Choice E reason: Epidemiology defines the burden of disease and determinants of health is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology estimates and compares the magnitude and severity of diseases and health problems, as well as their causes and risk factors, in different populations and settings.
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