The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

Choice A rationale

Assessing for hypotension is not indicative of fluid overload. Hypotension is more likely associated with hypovolemia or hemorrhage, whereas fluid overload manifests as signs of hypervolemia, including elevated blood pressure and pulmonary edema.

Choice B rationale

Assessing for distention above the pubis area identifies bladder retention or obstruction but is not directly related to monitoring fluid overload. Fluid overload affects systemic circulation and organ function rather than localized distention.

Choice C rationale

Monitoring laboratory values for hypernatremia is not an effective strategy for detecting fluid overload. Hypernatremia occurs due to inadequate water intake rather than excessive fluid administration. Fluid overload is typically identified by signs such as pulmonary congestion and generalized edema.

Choice D rationale

Maintaining strict intake and output records is crucial in detecting fluid overload. It helps identify disproportionate fluid retention compared to urinary output, signaling hypervolemia. Continuous monitoring ensures timely adjustments in fluid administration and prevents complications. .

Choice A rationale

Assessing energy levels provides indirect information about cardiac output but lacks specificity regarding fluid overload or pulmonary congestion, which are key indicators of heart failure exacerbation. It is a relevant question but not the best for evaluating treatment outcomes.

Choice B rationale

Asking about pillow use evaluates orthopnea, a common symptom of heart failure due to fluid buildup in the lungs when lying flat. It provides a direct assessment of fluid status and the effectiveness of heart failure management, making it the best question.

Choice C rationale

Exercising regularly is an important lifestyle aspect for heart failure patients but does not directly assess the status of symptoms such as fluid overload or cardiac function. Thus, it is not the most critical outcome measure.

Choice D rationale

Chest pain can indicate ischemia or worsening cardiac function but is not specific to fluid status or pulmonary congestion in heart failure. Therefore, it is a relevant but less optimal question for evaluating treatment goals.