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","D"]
Explanation
The correct answer is Choices B and D.
Choice A rationale: Using confrontation to manage a client’s behavior is not recommended, especially for clients with Alzheimer’s disease. Confrontation can lead to increased agitation, confusion, and distress in these clients. It’s important to approach clients with Alzheimer’s disease in a calm, reassuring manner and to validate their feelings and experiences.
Choice B rationale: Limiting the number of choices for the client is a beneficial strategy when caring for clients with Alzheimer’s disease. Too many choices can overwhelm these clients and lead to increased confusion and frustration. By simplifying decisions, caregivers can help to reduce the client’s stress and improve their ability to function.
Choice C rationale: While it’s important to keep clients with Alzheimer’s disease engaged and stimulated, providing a stimulating environment can be counterproductive. Too much stimulation can overwhelm these clients and lead to increased confusion and agitation. It’s more beneficial to provide a calm, quiet, and familiar environment for these clients.
Choice D rationale: Using written signs to assist the client with locating the bathroom can be very helpful for clients with Alzheimer’s disease. As the disease progresses, these clients often struggle with memory loss and disorientation. Clear, simple signs can help them navigate their environment and maintain a level of independence.
Correct Answer is A
Explanation
A. Correct. Chadwick's sign is a bluish or purplish discoloration of the vaginal and vulvar tissues due to increased vascularity that occurs during pregnancy. This is a normal finding in early pregnancy.
B. Incorrect. Chloasma refers to the appearance of dark patches on the skin, often seen on the face, and is not related to the vaginal and vulvar color changes seen in Chadwick's sign.
C. Incorrect. Hegar's sign refers to the softening of the cervix and isthmus of the uterus, not the color changes in the vaginal and vulvar tissues.
D. Incorrect. Ballottement is a physical examination technique used to assess a floating mass in the body, such as a fetus, and is not related to the color changes in the vaginal and vulvar tissues.
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