A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Document the findings and continue with the visit.

Notify the RN case manager of the change in status.

Reinforce the importance of daily weights.

Ensure the client has been taking their prescribed diuretic.

Answer and Explanation

The Correct Answer is B

A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.

B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.

C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.

D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Family history is a non-modifiable risk factor as it cannot be changed or controlled.
B. A sedentary lifestyle is a modifiable risk factor; increasing physical activity can reduce the risk of heart disease.
C. Smoking is a modifiable risk factor; quitting smoking can significantly decrease the risk of heart disease.
D. Diabetes can be managed and controlled through lifestyle changes and medication, making it a modifiable risk factor.
E. Hypertension is also a modifiable risk factor; it can be managed through diet, exercise, and medication.

A. "Your headache is probably a result of anxiety about the chest pain." B. "It sounds as if you are allergic to this medication." C. "A headache is a common adverse effect of this medication, but it will probably occur less often over time." D. "A headache indicates tolerance to the medication."

Correct Answer is C

Explanation

A. The headache is not related to anxiety but is a known side effect of nitroglycerin due to vasodilation.
B. An allergy to nitroglycerin typically presents as a rash or breathing difficulty, not a headache.
C. Nitroglycerin commonly causes headaches due to the dilation of blood vessels in the brain, which usually lessens over time as the body adjusts.
D. A headache does not indicate tolerance to the medication. Tolerance develops when the body becomes less responsive to the medication's effects, which usually involves a reduced effect on chest pain, not the onset of a headache.

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A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about risk factors for heart disease. Which of the following risk factors is modifiable? (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain. The client states that his chest pain is relieved but now he has a headache. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?