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: Vasopressin (Desmopressin) is not primarily used to decrease blood pressure. It is an antidiuretic hormone that helps manage diabetes insipidus by reducing urine output. While vasopressin can have vasoconstrictive effects, its primary role in this context is to control urine production, not blood pressure.

Choice B reason: The primary therapeutic outcome of vasopressin (Desmopressin) in a patient with diabetes insipidus is to decrease urine output. Diabetes insipidus leads to excessive urine production and dehydration. Vasopressin acts on the kidneys to increase water reabsorption, thereby reducing urine volume and helping to maintain fluid balance.

Choice C reason: Level of consciousness is not a direct therapeutic outcome of vasopressin (Desmopressin). While managing fluid balance can indirectly affect a patient's overall condition and well-being, vasopressin specifically targets the kidneys to reduce urine output and does not have a direct impact on consciousness levels.

Choice D reason: Specific gravity refers to the concentration of solutes in the urine. While vasopressin can affect the specific gravity by concentrating the urine and reducing volume, the primary therapeutic goal is to manage urine output in patients with diabetes insipidus. The focus is on reducing the excessive urine production rather than altering specific gravity.

A. Headaches can occur due to the vasoconstriction effect of the medication. B. I can give you some Morphine to help with that headache. C. I will notify the physician immediately. D. This is a normal side effect of Nitroglycerin as it dilates your body's vessels.

Correct Answer is D

Explanation

Choice A reason: The statement "Headaches can occur due to the vasoconstriction effect of the medication" is incorrect. Nitroglycerin causes vasodilation, not vasoconstriction. Vasodilation increases blood flow, which can lead to headaches as a common side effect.

Choice B reason: Offering Morphine to manage the headache is not the most appropriate initial response. While Morphine can relieve pain, it's essential to educate the patient about the common side effects of Nitroglycerin and provide reassurance. Morphine use should be carefully considered and is typically reserved for more severe pain management.

Choice C reason: Notifying the physician immediately is not necessary in this scenario, as a headache is a known and common side effect of Nitroglycerin. It's more appropriate to educate the patient about the side effects and provide reassurance. Only if the headache is severe and unrelieved by other measures should the physician be notified.

Choice D reason: Explaining that the headache is a normal side effect of Nitroglycerin, which dilates blood vessels, is the most appropriate response. This helps to reassure the patient and provides an understanding of why the headache is occurring. Nitroglycerin works by dilating blood vessels to improve blood flow and reduce angina symptoms, and headaches are a common side effect due to this vasodilation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving vasopressin (Desmopressin). The nurse understands the therapeutic outcome is a decrease in:

Correct Answer is B

Explanation

A patient with angina is receiving Nitroglycerin and begins to complain of a severe headache. What is the most appropriate response from the nurse?

Correct Answer is D

Explanation

The nurse is caring for a client who is receiving the ACE inhibitor lisinopril. Which of the following outcomes should the nurse anticipate?

The client is receiving IV doses of Vancomycin every 12 hours. Which would be the nurse's priority to monitor for complications during the period that the patient is receiving this drug?

A nurse cares for a patient who has a heart rate averaging 54 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate?

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The blood pressure is significantly elevated to 190/100. The first action by the nurse is to:

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?