A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Weigh every morning.

Perform range of motion exercises.

Limit fluid intake to 1,500 mL daily.

Eat a high protein diet.

Answer and Explanation

The Correct Answer is A

Regular weighing is an essential self-management strategy for clients with heart failure (HF). It helps monitor changes in fluid balance, which is crucial in managing HF symptoms. Sudden weight gain may indicate fluid retention, a worsening of HF, or the need for adjustments in medications or dietary restrictions. Daily weighing provides valuable information for both the client and healthcare provider to assess the effectiveness of the HF management plan.

While performing range of motion exercises and maintaining mobility are important for overall health, they may not be specifically related to the management of heart failure. The focus of discharge teaching for HF is typically on monitoring symptoms, medication management, diet and fluid restrictions, and when to seek medical attention.

Limiting fluid intake to 1,500 mL daily may be a general recommendation for some clients with HF, but it is best to individualize fluid restrictions based on the client's specific needs. The client should follow the fluid restriction prescribed by their healthcare provider, which may vary depending on the severity of HF and other individual factors.

While maintaining a balanced diet, including adequate protein intake, is important for overall health, there may be specific dietary recommendations for clients with HF that go beyond a general instruction to eat a high protein diet. Dietary instructions for HF clients typically include sodium restriction, fluid restriction if necessary, and considerations for comorbidities and medications.

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Correct Answer is D

Explanation

A) Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B) Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C) Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D) Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.

A. Blood pressure 130/80 mm Hg. B. Cervical spine stiffness. C. Dark yellow urine. D. Excessive perspiration.

Correct Answer is B

Explanation

A) Incorrect- A blood pressure of 130/80 mm Hg is within a generally acceptable range for a person with diabetes and coronary artery disease. It may not directly indicate a complication related to the episodes of confusion. While blood pressure management is important for clients with diabetes and coronary artery disease, this particular blood pressure reading is not necessarily a significant finding in relation to the client's confusion.
B) Correct- Cervical spine stiffness or neck stiffness is a potential neurological symptom that can indicate a serious complication in a client with type 2 diabetes and coronary artery disease. The stiffness of the neck may be a sign of meningeal irritation, which can result from various conditions including infections such as meningitis. The client's medical history includes both type 2 diabetes and coronary artery disease, which are risk factors for cardiovascular events, including cerebrovascular accidents (strokes). Confusion can be a symptom of a stroke, and neck stiffness can be indicative of meningeal irritation secondary to a stroke or another neurological condition.
C) Incorrect- Dark yellow urine can be a sign of dehydration, which can be a concern for someone with diabetes. However, it is not directly related to episodes of confusion. Dehydration can cause various symptoms, but confusion is not typically associated with mild dehydration.
D) Incorrect- Excessive perspiration (diaphoresis) can occur for various reasons, including increased sympathetic nervous system activity, fever, anxiety, and physical activity. While it can be a symptom of certain complications, such as hypoglycemia (low blood sugar) or heart attack, it alone may not directly relate to the episodes of confusion in this client.

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A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

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Naxlex Comprehensive Predictor Exams

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

Correct Answer is B

Explanation

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