The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

Assess breath sounds

Monitor serum protein levels

Assess peripheral pulses

Monitor daily weights

Answer and Explanation

The Correct Answer is D

D. Furosemide is a diuretic that works by increasing urine output, which in turn reduces fluid retention and swelling. By tracking the client's weight on a daily basis, the nurse can obtain a clear and consistent measure of how much fluid is being lost as a result of the medication.
A. Monitoring respiratory status but it may not be the most direct method for evaluating the effectiveness of furosemide in reducing peripheral edema.
B. Monitoring serum protein levels may provide information about the client's nutritional status and liver function, but it is not typically used as a direct measure of response to furosemide for peripheral edema.
C. Improvement in peripheral pulses may indicate a reduction in fluid overload and resolution of edema. However, changes in peripheral pulses may be influenced by factors other than diuresis, such as vascular disease or cardiac function.

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Correct Answer is D

Explanation

D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.

A. cannot answer the nurse when spoken to. B. may need complete supervision when performing hand hygiene. C. is allowed to use safety scissors with adult guidance. D. follows directions independently when given an assignment.

Correct Answer is B

Explanation

B. Children with IDD often require additional support and supervision in performing daily tasks, including personal hygiene routines like handwashing. Depending on the specific needs and abilities of the child, they may require varying levels of assistance and supervision.
A. Communication abilities can vary widely among children with IDD, and many may be able to understand and respond to simple questions or instructions, albeit with some difficulty.
C. Safety scissors are specifically designed for children to use safely, with features such as blunt tips and plastic blades to minimize the risk of injury. Allowing a child with IDD to use safety scissors with adult guidance can promote independence while ensuring safety.
D. Children with IDD often face challenges in following directions and completing tasks independently, particularly those with lower IQ scores.

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The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

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