The practical nurse (PN) is assisting with the admission of a client with complications of left- sided heart failure. Which focused assessment should the PN implement first?
Heart sounds
Mood and affect
Chest pain
Bilateral lung sounds
The Correct Answer is D
The correct answer is choice D - Bilateral lung sounds.
Choice A rationale:
Heart sounds. While assessing heart sounds is crucial, the question specifically mentions complications of left-sided heart failure, which primarily affects the lungs. Therefore, assessing lung sounds is a higher priority in this situation.
Choice B rationale:
Mood and affect. While assessing the client's mood and affect is important for holistic care, it is not the most critical assessment to implement first in the case of left-sided heart failure complications.
Choice C rationale:
Chest pain. Although chest pain may be a symptom of left-sided heart failure complications, assessing bilateral lung sounds takes precedence as it directly relates to the client's respiratory status.
Choice D rationale:
Bilateral lung sounds. In left-sided heart failure, fluid can accumulate in the lungs, leading to pulmonary congestion and impaired gas exchange. Therefore, assessing lung sounds helps identify any respiratory distress early on, allowing prompt intervention and prevention of further complications.
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Related Questions
Correct Answer is B
Explanation
This is the highest priority task and should be completed first because it ensures the safety and quality of care for the clients. The PN should check that all new prescriptions have been administered, documented, and reported as ordered and that there are no errors or omissions.
Correct Answer is A
Explanation
The injury description by the mother varies from the child's version.
Choice A rationale:
The practical nurse (PN) should note the significant indicator of possible child abuse, which is the discrepancy between the mother's description of the injury and the child's version. In cases of child abuse, perpetrators often provide inconsistent or conflicting explanations about how the injuries occurred, raising suspicion of maltreatment. This inconsistency can be a red flag for the PN to further assess the situation and, if necessary, report concerns to the appropriate authorities.
Choice B rationale:
While the child looking at the floor when answering questions might be a behavior worth noting, it alone is not a definitive indicator of child abuse. Children may exhibit various emotional responses for various reasons, and it requires further assessment to determine if there are signs of abuse.
Choice C rationale:
The healing of abrasions on the child's arms, legs, and chest does not necessarily indicate child abuse. Children are active and prone to minor injuries, which are a normal part of growing up. The PN should investigate further to determine the cause of the injuries.
Choice D rationale:
The mother describing in detail what she did for her injured child does not automatically suggest child abuse. It is essential for the PN to gather more information and conduct a comprehensive assessment before drawing any conclusions.
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