A nurse is providing discharge instructions for a client with a history of heart failure. Until a scale is obtained, which of the following instructions would be most helpful if the client does not have a scale at home to weigh on?
1. Wear the same belt in the same location around the waist and alert the physician if the belt becomes tighter.
2. Wear a name band around the wrist to see if it gets tighter.
3. Wear a ball cap every day to determine whether there is an increase in head circumference.
4. Discuss taking extra medication if the client feels there is weight gain.
Wear the same belt in the same location around the waist and alert the physician if the belt becomes tighter.
Rationale: If the client does not have access to a scale initially and is waiting to get one, the nurse can advise the client to utilize a piece of clothing, such as a belt, used in the same location, to help determine weight gain. Other methods might be to discuss awareness of socks or rings getting tight. The wrist and head circumference are not good locations to judge weight gain. Discussing taking extra medication based upon a client's feeling like there is weight gain is not advised without consulting the health care provider. The most reliable measurement of weight gain is utilizing scales.
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