Which clinical manifestation would the nurse use to indicate that the status of an older adult patient (greater than age 75) with chronic heart failure condition is worsening?

Presence of fine tremors

Heart rate 50 per minute

+1 peripheral edema

Increased confusion

Answer and Explanation

The Correct Answer is D

A. Presence of fine tremors: Fine tremors are not a typical sign of worsening heart failure. They may be associated with medications (like bronchodilators or lithium), metabolic issues, or neurologic disorders, but not directly with heart failure decompensation.

B. Heart rate 50 per minute: Bradycardia may be notable, especially in the context of beta-blocker therapy, but a heart rate of 50 bpm in a stable patient is not necessarily a sign of worsening heart failure unless accompanied by symptoms like dizziness or hypotension.

C. +1 peripheral edema: Mild peripheral edema is often chronic and common in older adults with heart failure. It does not reliably indicate worsening status unless there is a significant increase in edema or associated weight gain and pulmonary symptoms.

D. Increased confusion: Older adults are more susceptible to changes in cognitive function due to decreased cardiac output in worsening heart failure. New or worsening confusion in older adults is a key sign of decreased cerebral perfusion and may signal worsening heart failure. It can also indicate hypoxia or electrolyte imbalance, making it a critical finding that warrants immediate evaluation.

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Correct Answer is B

Explanation

A. Breast cancer treated with chemotherapy and radiation: While cancer and its treatments can suppress the immune system, they are not direct causes of infectious endocarditis. The condition is more closely related to bacteremia and structural heart damage.

B. Periodontal disease and gum surgery three months ago: Periodontal disease involves chronic bacterial infection of the gums and supporting structures of the teeth, this transient bacteremia can lead to infectious endocarditis. Oral infections and invasive dental procedures can introduce bacteria into the bloodstream, particularly streptococci, which can colonize damaged heart valves and cause infectious endocarditis.

C. Type II diabetic for ten years: Diabetes increases the risk of infection generally, but it is not a specific cause of endocarditis. Without a portal of entry or bacteremia, the condition alone is not strongly associated with endocarditis.

D. Myocardial infarction one year ago: A prior MI may result in reduced cardiac function but does not directly lead to infectious endocarditis unless it has resulted in damaged valves or introduced infection, which is not indicated here.

A. Administer an antidiarrheal medication B. Assess the pupils for constriction C. Provide frequent oral care D. Insert an indwelling catheter

Correct Answer is C

Explanation

A. Administer an antidiarrheal medication: Atropine is an anticholinergic agent that reduces gastrointestinal motility, often leading to constipation rather than diarrhea. Administering an antidiarrheal would not be appropriate and could cause harmful effects if unnecessary.

B. Assess the pupils for constriction: Atropine causes pupil dilation (mydriasis), not constriction. Checking for constriction would not align with the expected pharmacologic effects of the drug and is not a priority assessment after administration.

C. Provide frequent oral care: Atropine inhibits secretions as part of its anticholinergic effects, often leading to dry mouth (xerostomia). Frequent oral care helps maintain mucous membrane integrity and client comfort, making this an appropriate nursing action following administration.

D. Insert an indwelling catheter: Although atropine can cause urinary retention, especially in older adults, catheter insertion is not routinely required after administration; a single 0.5 mg IV dose is less likely to cause significant urinary retention requiring catheterization. It should only be considered if the client shows clinical signs of acute urinary retention.

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Which clinical manifestation would the nurse use to indicate that the status of an older adult patient (greater than age 75) with chronic heart failure condition is worsening?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with suspected infectious endocarditis. Which information obtained in the health history could contribute to the development of this problem?

Correct Answer is B

Explanation

The nurse administers atropine 0.5 mg IV to a client. Which action should be performed after the client has received this medication?

Correct Answer is C

Explanation

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