A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.
While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Rhythm of the apical pulse.

Volume of pedal pulses.

Degree of skin elasticity.

Length of capillary refill.

Answer and Explanation

The Correct Answer is A

Choice A rationale

In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.

Choice B rationale

While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice C rationale

The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice D rationale

The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

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Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A rationale

An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.

Choice B rationale

Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.

Choice C rationale

Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.

Choice D rationale

An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.

Choice E rationale

Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.

Choice F rationale

An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.

A. Fresh or frozen vegetables without sauce. B. Fruits without sauce. C. Cottage cheese. D. Pickled olives. E. Canned soup.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Fresh or frozen vegetables without sauce are a great choice for someone with hypertension. Vegetables are high in fiber and low in sodium, which can help lower blood pressure. They also contain potassium, which can help balance out the negative effects of sodium.

Choice B rationale

Fruits without sauce are also a good option. Like vegetables, fruits are high in fiber and potassium and low in sodium. They also contain other heart-healthy nutrients like antioxidants.

Choice C rationale

Cottage cheese is typically high in sodium, which can raise blood pressure. Therefore, it’s not the best choice for someone with hypertension.

Choice D rationale

Pickled olives are also high in sodium, making them a poor choice for someone with hypertension.

Choice E rationale

Canned soup is another food that’s typically high in sodium. While low-sodium versions are available, fresh soup made with low-sodium broth and plenty of vegetables would be a healthier choice.

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A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Nursing Test Bank

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A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.
While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?