The nurse cares for a client with diabetes mellitus and congestive heart failure.
Which two (2) client findings in the history and physical are most concerning? Select all that apply
Oral temperature
Thready pulse
Reports of thirst
Recently lost his job
Medical history of CHF
Correct Answer : B,D
Choice A rationale: While the temperature is important in assessing health, it isn't the most concerning finding in this scenario compared to others.
Choice B rationale: A thready pulse (a weak, barely palpable pulse) could indicate a critical drop in blood pressure and cardiac output, which is a significant concern.
Choice C rationale: While indicating a possible issue with hydration, it's not as immediately concerning as other findings in this context.
Choice D rationale: Recently lost his job - While this has social and economic implications, it's not an immediate physiological concern in this clinical scenario.
Choice E rationale: While significant in his overall health, it's not a direct finding from the current assessment that immediately raises concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: This is the correct answer. It corresponds to 300 mg of the drug ((300x 5)/250).
Choice B rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 200 mg of amoxicillin trihydrate, which is less than the prescribed dose of 300 mg.
Choice C rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 60 mg of amoxicillin trihydrate, which is not enough to treat an oral infection.
Choice D rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 250 mg of amoxicillin trihydrate, which is less than the prescribed dose of 300 mg.
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Correct Answer is ["A","C","E"]
Explanation
Choice A rationale: Correct. The statement is accurate because developing confusion could be a sign of a serious condition like severe electrolyte imbalance or dehydration, requiring immediate medical attention.
Choice B rationale: Incorrect. Fluid intake should not be arbitrarily limited without medical advice, especially for a client with diabetes insipidus. Maintaining a consistent fluid intake is crucial, and any changes should be guided by a healthcare provider.
Choice C rationale: Correct. Weighing oneself at the same time every day is a good practice for monitoring fluid balance and identifying sudden changes that may indicate a problem.
Choice D rationale: Incorrect. Desmopressin doses should be administered as prescribed. The medication's administration should be consistent with the healthcare provider's instructions or the medication guide, not arbitrarily altered.
Choice E rationale: Correct. Keeping a log of fluid intake and urine output is important for managing diabetes insipidus effectively and allows for informed adjustments in fluid intake or medication dosage.
Choice F rationale: Incorrect. Adjusting medication dosage without consulting a healthcare provider is not safe. While increased urination is a symptom of diabetes insipidus, the client should consult their healthcare provider if their symptoms persist or worsen, rather than self-adjusting the medication dose.
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