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 D

Explanation

A. Wearing gloves when removing food from the freezer is appropriate and helps prevent exposure to cold, which can trigger symptoms of Raynaud's phenomenon.
B. Completing a smoking cessation program is beneficial, as smoking can exacerbate symptoms of Raynaud's.
C. Avoiding stressful situations is advisable since stress can trigger vasoconstriction and exacerbate symptoms.
D. Keeping the house at a cool temperature is not recommended, as cold environments can provoke Raynaud's symptoms; the client should aim to maintain a warm environment to minimize triggers.

A. Nicardipine B. Phenytoin C. Dopamine D. Mannitol

Correct Answer is D

Explanation

A. Nicardipine is a calcium channel blocker primarily used to manage blood pressure but does not directly reduce ICP.
B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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