Which instruction would best reduce the symptoms of a client with heart failure and assure more comfort at home?

Explain ways to decrease paroxysmal nocturnal dyspnea.

Discuss the effects of medications, ways to assess fluid balance, and positions for enhancing respirations.

Teach stress management techniques.

Provide a list of support systems in the community.

Answer and Explanation

The Correct Answer is B

Choice A reason: Explaining ways to decrease paroxysmal nocturnal dyspnea is helpful for managing this specific symptom of heart failure, which involves difficulty breathing at night due to fluid accumulation in the lungs. While this can improve comfort, it doesn't provide a comprehensive approach to managing heart failure symptoms at home.

Choice B reason: Discussing the effects of medications, ways to assess fluid balance, and positions for enhancing respirations offers a comprehensive approach to managing heart failure symptoms at home. Understanding medication effects helps clients adhere to their treatment plan and manage side effects. Assessing fluid balance is crucial for detecting fluid overload early, a common issue in heart failure. Learning positions that enhance respirations can improve breathing and overall comfort.

Choice C reason: Teaching stress management techniques is beneficial for overall well-being and can indirectly improve heart health by reducing stress, which can exacerbate heart failure symptoms. However, it is not as directly related to managing the physical symptoms of heart failure as other interventions.

Choice D reason: Providing a list of support systems in the community is valuable for emotional and practical support, which can improve quality of life for clients with heart failure. However, it does not directly address the physical symptoms or management of heart failure at home.

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Correct Answer is B

Explanation

Choice A reason: A blood pressure of 158/90 mm Hg in a patient with chronic kidney disease (CKD) is elevated and requires management to prevent complications. However, it is not as immediately life-threatening as Kussmaul respirations, which indicate severe metabolic acidosis.

Choice B reason: The patient with Kussmaul respirations should be assessed first. Kussmaul respirations are deep, labored breathing patterns typically associated with severe metabolic acidosis, such as diabetic ketoacidosis (DKA) or severe kidney failure. This condition requires immediate intervention to correct the underlying acidosis and stabilize the patient's condition.

Choice C reason: Itching (pruritus) is a common symptom in CKD due to the accumulation of uremic toxins. While it can be very uncomfortable and requires treatment, it is not as urgent as Kussmaul respirations, which indicate a potentially life-threatening situation.

Choice D reason: Halitosis (bad breath) and stomatitis (inflammation of the mouth) can occur in CKD due to the buildup of uremic toxins and other factors. These symptoms need attention, but they do not indicate an immediate threat to the patient's life compared to Kussmaul respirations.

A. Medicate the patient for pain. B. Allow the patient to rest quietly. C. Assess the patient for bleeding. D. Document the findings in the chart.

Correct Answer is C

Explanation

Choice A reason: Medicating the patient for pain is not the most appropriate immediate action in this situation. While pain management is important, the primary concern should be addressing the significant changes in heart rate and blood pressure, which may indicate a more serious underlying issue.

Choice B reason: Allowing the patient to rest quietly is not the appropriate response to the noted changes in vital signs. The increase in heart rate and drop in blood pressure are signs that require immediate investigation and intervention, rather than passive observation.

Choice C reason: Assessing the patient for bleeding is the most appropriate action. The increase in heart rate and decrease in blood pressure following an angioplasty procedure are concerning for potential bleeding or hemorrhage, especially if the patient has an intra-arterial line. Quick assessment and intervention are crucial to address any bleeding and stabilize the patient's condition.

Choice D reason: Documenting the findings in the chart is necessary, but it should not be the immediate priority. The nurse must first assess and address the potential cause of the changes in vital signs, such as bleeding, before documenting the events.

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Which instruction would best reduce the symptoms of a client with heart failure and assure more comfort at home?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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