A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?
The client reports increased shortness of breath.
The client has a temperature of 37°C (98.6°F).
The client has a blood pressure of 120/80 mmHg.
The client reports occasional dizziness.
The Correct Answer is A
Choice A rationale
Increased shortness of breath is a key symptom of worsening congestive heart failure (CHF). It indicates that the heart is not effectively pumping blood, leading to fluid buildup in the lungs and increased respiratory effort.
Choice B rationale
A temperature of 37°C (98.6°F) is within the normal range and does not indicate worsening CHF. Monitoring the patient’s temperature is important, but it is not a sign of CHF exacerbation.
Choice C rationale
A blood pressure of 120/80 mmHg is within the normal range and does not indicate worsening CHF. Blood pressure should be monitored, but this reading does not suggest an acute issue.
Choice D rationale
Occasional dizziness can be a symptom of many conditions, including CHF, but it is not as specific or critical as increased shortness of breath. It should be monitored, but it does not indicate an immediate worsening of CHF.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Cellulitis is characterized by a red, swollen, and warm area on the skin, often accompanied by fever. It is a bacterial infection of the skin and underlying tissues.
Choice B rationale
Deep vein thrombosis (DVT) typically presents with swelling, pain, and warmth in the affected leg but not redness and fever as primary symptoms.
Choice C rationale
Osteomyelitis involves infection of the bone, presenting with localized pain, swelling, and fever, but not typically a red, swollen area on the skin.
Choice D rationale
Gout causes joint pain, swelling, and redness, usually in the big toe, but not a red, swollen area on the leg.
Correct Answer is A
Explanation
Choice A rationale
Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.
Choice B rationale
Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.
Choice C rationale
Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.
Choice D rationale
Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.
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