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
Chest pain
Bilateral lung sounds
Mood and affect
The Correct Answer is C
c) Bilateral lung sounds.
Explanation:
When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.
While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admited with complications of left-sided heart failure.
The other options are considered incorrect because they are not the priority assessments when admitting a client with complications of left-sided heart failure.
Option a) Heart sounds: While assessing heart sounds is important in evaluating cardiac function, the priority in this scenario is to assess for pulmonary congestion and impaired gas exchange. Assessing bilateral lung sounds allows the practical nurse to gather immediate information about the client's respiratory status and the presence of fluid in the lungs.
Option b) Chest pain: Chest pain is a significant symptom that should be assessed promptly, as it could indicate various cardiac or respiratory conditions. However, in this specific scenario, the priority is to assess for signs of pulmonary congestion, which can have a more immediate impact on the client's respiratory function.
Option d) Mood and affect: Assessing the client's mood and affect is important for a comprehensive assessment of their emotional well-being. However, when admitting a client with complications of left- sided heart failure, the priority is to assess their physical condition, particularly the respiratory status, to address any immediate concerns related to pulmonary congestion and impaired gas exchange.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- Child abuse is the intentional or neglectful physical, emotional, or sexual harm or injury of a child by a parent, caregiver, or another person who has a relationship of trust or responsibility with the child. Child abuse can have serious and long-lasting consequences for the child's health, development, and well-being.
- The practical nurse (PN) has a legal and ethical duty to identify, report, and prevent child abuse. The PN should be alert for any signs and symptoms of child abuse, such as unexplained or inconsistent injuries, bruises, burns, fractures, or scars; behavioural changes, such as fear, anxiety, aggression, withdrawal, or depression; poor hygiene, nutrition, or growth; lack of supervision, medical care, or education; or sexualized behaviours or knowledge.
- The PN should also conduct a thorough and sensitive assessment of the child and the family situation, using open-ended questions, active listening, and a non-judgmental attitude. The PN should compare the history and physical findings of the child with the expected developmental milestones and normal variations for the child's age and stage. The PN should also document any relevant information in an objective and factual manner.
- When the mother of a school-aged boy tells the PN that he fell out of a tree and hurt his arm and shoulder, the PN should assess the child's injury and compare it with the mother's explanation. The most significant indicator of possible child abuse in this scenario is if the injury description by the mother varies from the child's version. This may suggest that the mother is lying or covering up the true cause of the injury, which may be intentional or accidental harm by herself or someone else. A discrepancy between the mother's and the child's stories may also indicate that the child is afraid or coerced to hide the truth about the abuse.
- Therefore, option D is the correct answer, while options A, B, and C are incorrect.
- Option A is incorrect because the child looking at the floor when answering the nurse's questions may not be a sign of abuse, but rather a sign of shyness, embarrassment, pain, or discomfort.
Option B is incorrect because the mother describing in detail what she did for her injured child may not be a sign of abuse, but rather a sign of concern, care, or guilt.
Option C is incorrect because the abrasions on the child's arms, legs, and chest having healed may not be a sign of abuse, but rather a sign of normal wound healing or previous accidents.
Correct Answer is C
Explanation
Choice A reason: "Repeat dose in 1 hour for unrelieved headachE." This instruction is incorrect because sumatriptan should not be taken more than twice in 24 hours.
Choice B reason: "Chew tablet well before swallowinG." This instruction is unnecessary because sumatriptan tablets are meant to be swallowed whole with water.
Choice C reason: "If you experience chest pain, call your physician immediately." This instruction is important because sumatriptan can cause coronary vasospasm, which can lead to angina or myocardial infarction.
Choice D reason: "Take daily to prevent headaches." This instruction is inappropriate because sumatriptan is used to treat acute migraine attacks, not to prevent them.
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