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 C
Explanation
Choice A reason: Completing a survey of the various ethnicities represented in the nurse's community is a good way to learn about the diversity of the population, but it is not the first step in developing cultural competencE. The nurse should first examine their own cultural background and biases before learning about others.
Choice B reason: Studying the beliefs and traditions of persons living in other cultures is a valuable way to gain knowledge and understanding of different worldviews, but it is not the first step in developing cultural competencE. The nurse should first be aware of their own cultural values and assumptions before exploring those of others.
Choice C reason: Considering how the nurse's own personal beliefs and decisions are reflective of their culture is the first step in developing cultural competencE. The nurse should recognize that their culture influences their perception, communication, and behavior, and that they may have prejudices or stereotypes that affect their interactions with clients from different cultures.
Choice D reason: Inviting a family from another culture to join the nurse for an event is a nice gesture to show respect and interest in other cultures, but it is not the first step in developing cultural competencE. The nurse should first develop self-awareness and sensitivity to their own cultural identity before engaging with others.
Correct Answer is D
Explanation
Choice A reason: Proactive prevention is not a level of prevention, but a type of prevention that involves anticipating and avoiding potential health problems before they occur.
Choice B reason: Secondary prevention is a level of prevention that involves screening, early detection, and prompt treatment of health problems to prevent complications and limit disability.
Choice C reason: Tertiary prevention is a level of prevention that involves rehabilitation, restoration, and support of health and function after a health problem has caused damage or disability.
Choice D reason: Primary prevention is a level of prevention that involves health promotion and protection of health and well-being by reducing or eliminating risk factors and preventing the onset of disease or injury.
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