A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath
Which assessment should the nurse complete first?
a. Skin turgor
b. Heart sounds
c. Mental status
d. Capillary refill
ANS: C
Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.
You might also like to view...
The benchmarks of a good listener include all of the following except
a. Taking time b. Not interrupting c. Asking appropriate questions d. Assuming you know what the person is going to say
Objective data the nurse would include after a patient assessment includes:
a. headache of 3 days duration. b. severe stomach cramps. c. flatulence. d. anxiety.
The nurse administers intradermal injections for allergy testing. Which is the best nursing intervention for the nurse to implement for skin testing?
1. Selects a 22-gauge needle 2. Injects at a 45-degree angle 3. Chooses the back for first test 4. Injects below antecubital space
The nurse reviews the medication treatment regimen for a patient with chronic hypertension. To promote optimal medication adherence, which frequency of drug dosing should the nurse advocate for this patient?
A. Once a day B. Three times a day C. Four times a day D. Every 8 hours