The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?
"How many pillows do you sleep on mister"
"Do you have chest pain when you walk up the steps?"
"Do you find that your rings and shoes feel tight at the end of the day?"
"How many times do you get up to void at night?"
The Correct Answer is A
A. This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B. Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C. Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D. Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Ventricular fibrillation (VF) is characterized by a chaotic, rapid, and irregular electrical activity on the ECG, with no identifiable QRS complexes, P waves, or T waves. The heart quivers ineffectively, leading to no blood flow or cardiac output, which results in rapid loss of consciousness and is life-threatening.
Immediate defibrillation is required to restore a normal rhythm. A high-energy shock is delivered to the heart to reset the electrical activity, potentially allowing the heart's natural pacemaker to regain control and resume normal function.
Correct Answer is A
Explanation
A. Petechiae (small, pinpoint hemorrhages) are a common manifestation of DIC due to the excessive clotting and subsequent breakdown of clotting factors, leading to bleeding into the skin.
B. Diarrhea is not typically a primary symptom of DIC, although gastrointestinal bleeding can occur in severe cases.
C. Intractable vomiting is not characteristic of DIC, although it could occur in clients with severe bleeding or complications.
D. Urinary incontinence is not a direct manifestation of DIC, although it could occur secondary to neurological or other systemic complications.
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