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
Explanation
This statement shows that the client understands the importance of monitoring the color of the stoma and seeking medical attention if any concerning changes occur. A purple or dark discoloration of the stoma can indicate inadequate blood supply to the area, which requires immediate medical evaluation.
"I will irrigate the colostomy every day." Colostomy irrigation is not typically done every day. It is a procedure used for some individuals with specific types of colostomies to establish a regular bowel movement pattern. The frequency and need for colostomy irrigation should be discussed and determined with the healthcare provider.
"I should expect my stool to be formed." Depending on the location and type of colostomy, the consistency of stool can vary. In the case of an ascending colostomy, the stool is usually liquid or semi-liquid because it is closer to the beginning of the large intestine. Expecting formed stool with an ascending colostomy would not be accurate.
"I will no longer be able to eat nuts." The ability to eat nuts or any other specific foods will depend on individual tolerance and the advice of a healthcare provider. In general, having a colostomy does not mean that all foods need to be eliminated from the diet. A well-balanced and varied diet can still be maintained with appropriate consideration for individual preferences and any dietary restrictions based on the specific situation.
Correct Answer is A
Explanation
A. Correct. This response acknowledges the client's feelings and demonstrates empathy. It opens the door for further discussion and exploration of the client's beliefs without immediately challenging them.
B. Incorrect. Directly contradicting the client's beliefs may cause resistance and increase their distress. It's important to approach the situation with sensitivity and understanding.
C. Incorrect. While asking for clarification is a valid approach, it may not be the most appropriate initial response. It's important to establish trust and rapport with the client before delving into their delusional beliefs.
D. Incorrect. Asking "why" s may put the client on the defensive and may not lead to a productive conversation about their beliefs. It's better to approach the situation with empathy and openness before exploring the client's perspective.
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