Exhibits

A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing: Heart failure.

The client presents with signs and symptoms consistent with heart failure, including cardiomegaly, bibasilar pleural congestion on chest x-ray, elevated BNP level, and vital signs indicating hypertension (BP 146/98 mm Hg), tachycardia (pulse rate 106/min), and tachypnea (respirations 24/min). Additionally, the client is prescribed medications commonly used to manage heart failure, such as digoxin and carvedilol, and is receiving a diuretic (furosemide) to address fluid overload associated with heart failure.
Action to Take:

Elevate the head of the bed: Elevating the head of the bed helps reduce venous return to the heart, decreasing preload and potentially alleviating symptoms of heart failure, such as dyspnea and orthopnea. It can also help prevent aspiration in clients with compromised cardiac function. Encourage intake of a low-sodium diet: A low-sodium diet is essential in managing heart failure as it helps reduce fluid retention and edema by decreasing fluid volume overload. Sodium restriction helps minimize fluid accumulation, which is crucial in preventing exacerbations of heart failure.
Parameter to Monitor:

Urinary output: Monitoring urinary output is important in assessing fluid balance and response to diuretic therapy in clients with heart failure. Decreased urinary output may indicate worsening heart failure or inadequate response to diuretic therapy, whereas increased output may suggest over-diuresis or improvement in heart failure symptoms.
Blood pressure: Monitoring blood pressure helps assess the effectiveness of treatment in managing heart failure and controlling hypertension, a common comorbidity. Hypertension can exacerbate heart failure, so monitoring blood pressure trends helps guide adjustments in medication therapy to achieve optimal blood pressure control and improve cardiac function.

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

Explanation

A. Confusion and restlessness: Confusion and restlessness can indicate changes in cerebral perfusion as the body begins to shut down. These signs may occur as death approaches.

B. Increased appetite and thirst: Increased appetite and thirst are less likely as death approaches.

In fact, clients often have decreased appetite and thirst as the body's systems slow down.

C. Increase in urinary and bowel output: As death approaches, urinary and bowel output typically decrease as the body's metabolic processes slow down.

D. Increased fatigue and sleep: Increased fatigue and sleepiness are common as death approaches. The body's energy levels decrease, leading to increased periods of sleep and rest.

E. Excess secretions in the throat and decrease swallow reflex: Excess secretions in the throat and a decrease in the swallow reflex can occur as the body's ability to manage secretions diminishes. This can lead to a gurgling sound in the throat known as the death rattle.

A. "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis." B. "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." C. "Cysts compress renal tissue, which destroys the kidneys, causing this diagnosis." D. "Immune complexes form in the kidney tissue and produce inflammation, causing this diagnosis."

Correct Answer is A

Explanation

A. "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis." Chronic renal disease often develops as a complication of long-standing

hypertension. Persistent high blood pressure can damage the small blood vessels in the kidneys, reducing blood flow and causing kidney tissue damage over time.

B. "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." This statement describes changes seen in conditions like diabetic nephropathy but is not specific to the development of renal disease in hypertension.

C. "Cysts compress renal tissue, which destroys the kidneys, causing this diagnosis." This statement describes the pathogenesis of polycystic kidney disease, not chronic renal disease due to hypertension.

D. "Immune complexes form in the kidney tissue and produce inflammation, causing this diagnosis." This statement describes the pathogenesis of glomerulonephritis, not chronic renal disease due to hypertension.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving hospice care in the home. The family asks, "how will we know when death is near?" The nurse should inform the family that which of the following signs indicates that death is approaching? (Select all that apply.)

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

Explanation

A client with a history of hypertension and diagnosis of chronic renal disease asks a nurse how the disease occurred. The nurse should accurately respond to the client by making which statement?

Correct Answer is A

Explanation

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