While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the client lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the client's discharge the nurse will facilitate a
transfer to a long-term care facility.
arrangements for around-the-clock care.
consult with a psychologist.
referral to a home health care agency.
The Correct Answer is D
A. Transfer to a long-term care facility is not necessary unless the client is unable to live independently despite support.
B. Around-the-clock care is excessive for a client who can still live alone and just needs assistance with medication management.
C. A psychologist is not the appropriate referral unless there are clear signs of mental health issues.
D. Referral to a home health care agency is appropriate to support the client at home, provide medication education, monitor adherence, and reduce the risk of readmission due to medication errors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Atrial Fibrillation
The client presents with an irregular, tachycardic rhythm with unclear P waves, which are classic signs of atrial fibrillation (AF). Symptoms such as palpitations, dizziness, and shortness of breath are common with AF, particularly with a rapid ventricular response.
Actions to Take
• Administer an anticoagulant: AF increases the risk of thrombus formation in the atria, which can lead to embolic stroke. Anticoagulation reduces this risk, especially in symptomatic or persistent cases.
• Obtain a 12-lead ECG: This helps confirm the diagnosis, assess the rhythm in detail, and rule out other arrhythmias or ischemic changes that may be present.
Parameters to Monitor
• Manifestations of stroke: Clients with AF are at increased risk for embolic stroke. Neurological status should be closely monitored for signs of confusion, facial droop, weakness, or speech changes.
• PTT/INR: These lab values help assess coagulation status, particularly when anticoagulants such as warfarin or heparin are initiated, to ensure therapeutic levels and avoid bleeding complications.
Correct Answer is B
Explanation
A. Circulating blood volume is decreased – This is true specifically in hypovolemic shock, but it does not apply to all types of shock (e.g., septic or cardiogenic shock).
B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients – This is the most accurate and comprehensive description of the pathophysiology of shock. Shock is defined as a state of cellular and tissue hypoperfusion, regardless of the underlying cause.
C. Hemorrhage occurs as a result of trauma – While hemorrhage can cause hypovolemic shock, it is not the universal cause of all types of shock.
D. Blood is shunted from vital organs to peripheral areas of the body – The opposite is true in shock: blood is typically shunted away from peripheral tissues to preserve perfusion to vital organs like the brain and heart.
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