A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Volume of pedal pulses.

Length of capillary refill.

Rhythm of apical pulse.

Degree of skin elasticity.

Answer and Explanation

The Correct Answer is C

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

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Correct Answer is B

Explanation

Rationale

A. Fruits can sometimes increase stool acidity or frequency in infants, potentially aggravating diaper rash. However, unless there is a clear association between fruit intake and exacerbation of symptoms, restricting fruits for 24 hours may not directly address the current rash. It's more important to focus on topical care and diaper hygiene.

B. Changing diapers frequently helps keep the skin dry and reduces exposure to irritants like urine and stool. This intervention is crucial as prolonged exposure to moisture can contribute to diaper rash development and exacerbation.

C. Applying a barrier cream or diaper rash ointment can protect the skin from moisture and irritants, providing a protective layer that promotes healing. This intervention helps soothe the skin and prevent further irritation.

D. Using soap and water at every diaper change can be harsh on the delicate skin of infants, especially if the soap is not pH-balanced or contains fragrances. Plain water or a gentle, pH-balanced cleanser is preferable to avoid further irritation.

A. Review medications for drug and food interactions. B. Observe carefully for extrapyramidal symptoms (EPS) C. Appraise light sensitivity, tiredness, and dizzy spells. D. Encourage the client to engage in social activities.

Correct Answer is A

Explanation

Rationale

A. Older adults are more susceptible to medication side effects due to changes in metabolism and polypharmacy. Reviewing the client's current medications, including over-the-counter medications for allergies and insomnia, can identify potential culprits.

B. Some medications used for allergies or insomnia, such as antihistamines or sedatives, can cause EPS in older adults. EPS include symptoms like tremors, rigidity, or involuntary movements. These symptoms can indicate adverse reactions that require immediate attention and adjustment of medication.

C. These symptoms could be side effects of medications commonly used for allergies and insomnia. They may also indicate other underlying health issues or medication interactions. Assessing these symptoms helps in determining their severity and whether they require further evaluation or intervention.

D. Social isolation can contribute to changes in behavior, especially in older adults. While social activities are beneficial for mental health, in this case, addressing the potential medication-related issues (options A and B) takes precedence to ensure the client's safety and well-being.

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A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

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Naxlex Comprehensive Predictor Exams

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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