The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Weigh patient using bed scale and restrict oral fluids.

Obtain pulse oximetry levels and assess the respiratory status.

Elevate lower extremity on two pillows while patient is in bed.

Obtain a Physical Therapy consultation to evaluate activity tolerance.

Answer and Explanation

The Correct Answer is B

Choice A reason: Weighing the patient using a bed scale and restricting oral fluids are important interventions for managing fluid balance in heart failure, but they are not the immediate priority. Assessing the respiratory status takes precedence to ensure the patient is not in respiratory distress.

Choice B reason: Obtaining pulse oximetry levels and assessing the respiratory status are priority actions. Dyspnea on exertion and fatigue indicate potential respiratory compromise, and it is crucial to evaluate oxygenation and respiratory function immediately.

Choice C reason: Elevating the lower extremity on two pillows while the patient is in bed can help reduce edema but is not the immediate priority. Respiratory assessment and stabilization take precedence.

Choice D reason: Obtaining a Physical Therapy consultation to evaluate activity tolerance is beneficial for long-term management but is not an immediate priority in acute care. The focus should be on assessing and stabilizing the patient's respiratory and cardiac status.

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Correct Answer is C

Explanation

Choice A reason: Foot ulcers and delayed wound healing are related to diabetes but are considered macrovascular complications. Microvascular complications specifically refer to damage to small blood vessels.

Choice B reason: Stroke prevention and cardiac health are important but are related to macrovascular complications of diabetes. The focus here is on microvascular complications.

Choice C reason: Retinopathy and nephropathy are microvascular complications of diabetes. These conditions result from damage to small blood vessels in the eyes and kidneys, respectively. Diabetic retinopathy can lead to vision loss, while diabetic nephropathy can lead to kidney failure. It is important to monitor for these complications and manage blood glucose levels to prevent or slow their progression.

Choice D reason: Hypertension management and cholesterol control are important for overall cardiovascular health but are related to macrovascular complications. The discussion should focus on microvascular complications specific to diabetes.

A. Your family history of common bile duct disorder is a trigger for this disease. B. The frequent occurrence of blood in your stool is the main cause of your IBS. C. People with a family history of psychiatric disorders and food allergies are more likely to get IBS. D. Environmental and psychosocial factors can be associated with the onset of this disease.

Correct Answer is D

Explanation

Choice A reason: Family history of common bile duct disorder is not a known trigger for irritable bowel syndrome (IBS). IBS is a functional gastrointestinal disorder with multifactorial causes, including but not limited to genetics, gut-brain axis, and environmental factors. Bile duct disorders and IBS have different pathophysiological mechanisms and are not directly linked.

Choice B reason: The frequent occurrence of blood in the stool is not a cause of IBS. Blood in the stool is more indicative of other gastrointestinal conditions such as inflammatory bowel disease (IBD), colorectal cancer, or haemorrhoids. IBS is characterized by abdominal pain, bloating, and changes in bowel habits without organic pathology such as bleeding.

Choice C reason: While there is some evidence suggesting that individuals with a family history of psychiatric disorders and food allergies may have a higher prevalence of IBS, it is not the main cause. These factors may contribute to the onset and exacerbation of symptoms but are part of a broader spectrum of triggers, including genetics, stress, and gut microbiota.

Choice D reason: Environmental and psychosocial factors are indeed associated with the onset of IBS. Factors such as stress, anxiety, depression, and traumatic life events can play a significant role in the development and exacerbation of IBS symptoms. Additionally, environmental factors like diet, infections, and changes in gut microbiota are known to influence IBS. This choice aligns with current evidence-based understanding of the condition.

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The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is discussing microvascular complications of diabetes with a patient. What topics will the nurse include in the discussion?

Correct Answer is C

Explanation

The nurse is caring for a patient with a new diagnosis of irritable bowel syndrome (IBS). The patient is upset and concerned about how they got IBS. What evidence-based information, related to the causes of IBS, will the nurse provide to this patient?

Correct Answer is D

Explanation

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