Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?
Explain the association between dysrhythmias and syncope.
Tell the patient about the benefits of implantable cardioverter-defibrillators.
Instruct the patient to call for assistance before getting out of bed.
Teach the patient about the need to avoid caffeine and other stimulants.
The Correct Answer is C
For a patient admitted with syncopal (fainting) episodes of unknown origin, the most appropriate action to include in the plan of care is to instruct the patient to call for assistance before getting out of bed.
Syncope can be caused by various factors, including orthostatic hypotension (a drop in blood pressure upon standing) or cardiac-related issues. One of the common triggers for syncopal episodes is getting up from a lying or sitting position too quickly. By instructing the patient to call for assistance before getting out of bed, the nurse aims to prevent falls and potential injuries that may occur due to sudden fainting episodes.
While it's essential to educate the patient about potential causes of syncope (option A) and the benefits of implantable cardioverter-defibrillators (option B) if applicable to their condition, these actions may not directly address the immediate safety concern of preventing falls during syncopal episodes.
Option D, teaching the patient about the need to avoid caffeine and other stimulants, may be relevant if stimulants are identified as potential triggers for syncope in this particular patient. However, it is not the most critical action to include in the initial plan of care for a patient with syncopal episodes of unknown origin.
In summary, the top priority for the nurse is to ensure the safety of the patient by instructing them to call for assistance before getting out of bed to prevent falls during syncopal episodes until further evaluation and diagnosis can determine the cause of the fainting episodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Chronic kidney disease (CKD) is a condition where the kidneys are damaged or unable to filter blood effectively over time, leading to a gradual loss of kidney function. Several risk factors can increase the likelihood of developing CKD, and among them, diabetes and hypertension are the most common.
Diabetes is a significant risk factor for developing CKD. It can cause damage to the small blood vessels in the kidneys, impairing their ability to filter waste and fluid from the blood properly. Native Americans, along with other racial and ethnic minorities, are at a higher risk of developing diabetes compared to the general population.
While hypertension (high blood pressure) is also a risk factor for CKD, diabetes carries a higher risk. However, it's important to note that hypertension is often a comorbidity associated with CKD and can further worsen kidney function when present.
The other options listed (a 50-year-old white female with hypertension, a 40-year-old Hispanic female with cardiovascular disease, and a 28-year-old African American female with a urinary tract infection) are also at risk for CKD, but the 61-year-old Native American male with diabetes is at the highest risk based on the information provided. All patients should be educated about preventive measures to protect their kidney health, but special attention should be given to individuals with diabetes due to its significant impact on kidney function.
Correct Answer is ["A","B","D"]
Explanation
A) Potassium: CKD can lead to hyperkalemia (high potassium levels) as the kidneys lose their ability to excrete potassium effectively. Limiting potassium intake helps prevent elevated potassium levels and reduces the risk of cardiac arrhythmias.
B) Calcium: In CKD, impaired kidney function can lead to abnormalities in calcium and phosphorus metabolism, which can result in secondary hyperparathyroidism. Limiting calcium intake can help manage the imbalances in calcium and phosphorus levels.
(D) Phosphorus: Impaired kidney function in CKD leads to decreased phosphate excretion, resulting in hyperphosphatemia (high phosphorus levels). High phosphorus levels can lead to bone disease and other complications, so limiting phosphorus intake is essential.
Iron (C) is not typically limited in the diet of a client with CKD unless they have iron overload or specific conditions that warrant iron restriction.
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