Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?
Explain the association between dysrhythmias and syncope.
Tell the patient about the benefits of implantable cardioverter-defibrillators.
Instruct the patient to call for assistance before getting out of bed.
Teach the patient about the need to avoid caffeine and other stimulants.
The Correct Answer is C
For a patient admitted with syncopal (fainting) episodes of unknown origin, the most appropriate action to include in the plan of care is to instruct the patient to call for assistance before getting out of bed.
Syncope can be caused by various factors, including orthostatic hypotension (a drop in blood pressure upon standing) or cardiac-related issues. One of the common triggers for syncopal episodes is getting up from a lying or sitting position too quickly. By instructing the patient to call for assistance before getting out of bed, the nurse aims to prevent falls and potential injuries that may occur due to sudden fainting episodes.
While it's essential to educate the patient about potential causes of syncope (option A) and the benefits of implantable cardioverter-defibrillators (option B) if applicable to their condition, these actions may not directly address the immediate safety concern of preventing falls during syncopal episodes.
Option D, teaching the patient about the need to avoid caffeine and other stimulants, may be relevant if stimulants are identified as potential triggers for syncope in this particular patient. However, it is not the most critical action to include in the initial plan of care for a patient with syncopal episodes of unknown origin.
In summary, the top priority for the nurse is to ensure the safety of the patient by instructing them to call for assistance before getting out of bed to prevent falls during syncopal episodes until further evaluation and diagnosis can determine the cause of the fainting episodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Resumption of sexual activity after a myocardial infarction (MI) is an important topic to address as part of the overall recovery and rehabilitation process. It should be discussed along with other physical activities during the patient's recovery. The nurse should initiate the discussion in a supportive and non-judgmental manner, addressing the patient's concerns, fears, and questions about sexual activity after an MI.
Sexual activity is a normal part of life, and patients may have concerns about the safety and appropriateness of engaging in sexual activity after a significant cardiac event like an MI. Discussing it along with other physical activities helps normalize the topic and allows the nurse to provide accurate information, address any misconceptions, and offer guidance on when and how to resume sexual activity safely. Patients should be encouraged to have an open dialogue with their healthcare provider about their concerns and any specific questions they may have related to resuming sexual activity.
Correct Answer is C
Explanation
The statement "I will call the clinic if my weight goes up 3 pounds in a week" indicates that the teaching about heart failure was effective. Monitoring weight is an essential self-care measure for patients with heart failure to manage fluid retention effectively. A sudden weight gain of 2-3 pounds in a week can indicate fluid retention and worsening heart failure. It is crucial for the patient to report such weight changes promptly to the healthcare provider or clinic to adjust medication doses or treatment plans as needed.
The other statements are incorrect:
A) "I will use the nitroglycerin patch whenever I have chest pain." Nitroglycerin is not typically used to manage heart failure. It is used for angina, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed coronary arteries.
B) "I will take furosemide (Lasix) every day just before bedtime." While furosemide is a diuretic commonly prescribed for heart failure to reduce fluid retention, it is not usually taken just before bedtime. Taking furosemide in the evening may lead to frequent nighttime urination and disrupt sleep.
D) "I will use an additional pillow if I am short of breath at night." Using an extra pillow may provide temporary relief for positional dyspnea (shortness of breath when lying flat) but is not an appropriate long-term strategy for managing heart failure. Elevated pillows may not effectively improve breathing and can lead to neck strain. Instead, patients with heart failure should be encouraged to sleep with their head slightly elevated on a regular basis, using a wedge pillow or adjustable bed if needed. Managing fluid retention and adhering to prescribed medications are essential for improving heart failure symptoms and preventing complications.
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