A nurse educator in a geriatric medicine unit of a hospital is teaching a group of new graduates specific assessment criteria related to heart failure
Which of the following assessment criteria should the nurses prioritize in their practice?
A)
Measurement of urine output and mental status assessment
B)
Pupil response and counting the patient's apical heart rate
C)
Palpation of pedal (foot) pulses and pain assessment
D)
Activity tolerance and integumentary inspection
Ans:
A
Feedback:
Both increased and decreased urine output can be markers of heart failure, as can changes in mental status not attributable to other factors. While heart auscultation, pedal pulses, and activity tolerance are relevant parameters, integumentary inspection, pupil response, and pain assessment are less likely to be relevant assessment components.
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