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?"

Answer and Explanation

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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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.

A. Prothrombin time, fibrin level and eosinophil count B. Fibrin degradation products, lactic acid and complete blood count C. D-dimer, fibrinogen and fibrin degradation products D. Complete blood count, Complete metabolic panel and prothrombin time

Correct Answer is C

Explanation

A. This test set is incomplete for diagnosing DIC. While PT and fibrinogen are important, the eosinophil count is not a key test for DIC.
B. While fibrin degradation products are useful, lactic acid is not specific for DIC and may indicate other issues. A complete blood count is helpful but not definitive for diagnosing DIC.
C. These are key markers for DIC. An elevated D-dimer indicates clot formation and breakdown, while fibrinogen and fibrin degradation products are used to assess clotting and fibrinolysis, both of which are abnormal in DIC.
D. Complete blood count, complete metabolic panel, and prothrombin time are general tests and can give some clues, but they are not definitive for diagnosing DIC.

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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?

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Naxlex Comprehensive Predictor Exams

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