A nurse is assisting with the care of a client in an outpatient provider's office.
The nurse should identify that the client is at risk of developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The nurse should identify that the client is at risk of developing heart failure and may require further assessment and intervention.
Heart failure is suggested by the progressive decline in vital signs and laboratory results, such as increasing BUN and creatinine levels, which indicate worsening kidney function and can contribute to heart failure. The client’s fatigue, weakness, bilateral edema, and crackles in the lungs are clinical signs consistent with heart failure. The dry, flaky skin and coarse, thinning hair also reflect systemic issues that could be associated with heart failure and poor nutritional status.
The nurse should focus on further assessment to evaluate the severity of heart failure and intervention to manage symptoms, potentially including medication adjustments, fluid management, and additional diagnostic testing. These steps are crucial to addressing the client’s deteriorating condition and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Vertigo is common after inner ear surgery like stapedectomy and can be related to changes in the inner ear. It should be monitored, but it's not an immediate concern unless severe.
B. Correct. A change in facial symmetry (left facial droop) is indicative of potential facial nerve dysfunction, which requires immediate attention.
C. Pupils are reactive to light, and their size is within the expected range, indicating normal pupillary function.
D. A pain rating of 5 on a scale of 0 to 10 indicates moderate pain. While it requires attention, it's not a critical concern.
E. Correct. Diminished hearing following ear surgery is an expected finding, but the nurse should assess the degree and type of hearing loss and communicate this to the healthcare provider.
F. Lung assessment is important but does not require immediate action based on the given information.
Correct Answer is A
Explanation
The correct answer is Choice A, Hot cocoa.
Choice A rationale:
Hot cocoa contains the least amount of caffeine among the options provided.A standard 240 mL (8 oz) cup of hot cocoa contains approximately 5 mg of caffeine. This is significantly less than the other beverages listed. Hot cocoa is made by adding cocoa powder and sugar or chocolate syrup to hot milk.The drink contains very little cacao, so the caffeine content is very low. Therefore, if a client is looking to reduce their dietary caffeine intake, hot cocoa would be a suitable choice.
Choice B rationale:
A cola soft drink contains more caffeine than hot cocoa.A standard 240 mL (8 oz) serving of a cola soft drink contains approximately 24-31 mg of caffeine. Cola is a popular flavor of soda around the world.Although the kola nut, from which the flavor of cola soda comes from, does naturally contain caffeine, the majority of the caffeine in cola is added by the manufacturer. Therefore, a cola soft drink would not be the best choice for a client looking to reduce their caffeine intake.
Choice C rationale:
Instant coffee contains even more caffeine.A standard 240 mL (8 oz) cup of instant coffee contains approximately 57-96 mg of caffeine.With instant coffee, caffeine measurements are based on the amount of the instant coffee powder used to make the drink. The caffeine content of coffee itself varies enormously.According to the USDA, 1 rounded teaspoon of instant coffee (1.8 grams in weight) contains 57 mg of caffeine.No matter how much water, milk, or creamer you add to the coffee - the amount of caffeine will remain the same. Therefore, instant coffee would not be a suitable choice for a client looking to reduce their caffeine intake.
Choice D rationale:
Brewed green tea also contains more caffeine than hot cocoa.An 8-ounce (240 mL) cup of green tea generally supplies around 20 to 45 milligrams of caffeine.This makes green tea a gentler alternative in terms of caffeine content, suitable for those who prefer a milder pick-me-up. However, it still contains more caffeine than hot cocoa. Therefore, while green tea is a healthier choice compared to cola soft drinks and instant coffee, it still contains more caffeine than hot cocoa.
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