The nurse is educating a client with heart failure on monitoring for signs and symptoms. Which statement by the client indicates appropriate understanding of the teaching session?
1. "I should weigh myself every day."
2. "As long as I'm not short of breath, I don't have heart failure."
3. "If I sleep on three pillows, I will be fine."
4. "My heart rate and blood pressure would be high."
Correct Answer: 1
Rationale 1: Increased daily weight is a sign that a client could be decompensating. Daily weights are an effective means of monitoring for heart failure symptoms.
Rationale 2: Shortness of breath is not present in all stages of heart failure. Moreover, many clients self-treat shortness of breath by doing progressively less activity, and therefore never experience shortness of breath until late in the disease.
Rationale 3: Clients with heart failure often experience orthopnea, which is relieved by sitting up. Sleeping on three pillows can mask orthopnea.
Rationale 4: High heart rate and blood pressure are compensatory mechanisms and signs that the client still might be experiencing heart failure.
Global Rationale: Increased daily weight is a sign that a client could be decompensating. Daily weights are an effective means of monitoring for heart failure symptoms. Shortness of breath is not present in all stages of heart failure. Moreover, many clients self-treat shortness of breath by doing progressively less activity, and therefore never experience shortness of breath until late in the disease. Clients with heart failure often experience orthopnea, which is relieved by sitting up. Sleeping on three pillows can mask orthopnea. High heart rate and blood pressure are compensatory mechanisms and signs that the client still might be experiencing heart failure.
You might also like to view...
When a 25-year-old client asks the nurse how she can lower her risk of breast cancer, the nurse would suggest that the client
a. have a mammogram every 2 years. b. increase her intake of leafy green vegetables. c. increase her intake of vitamin C. d. minimize intake of alcohol.
While performing a self-breast exam, the client notes an area on the right breast that is nodular, with some associated tenderness. This is a new onset finding because the exams were not problematic in the past,
The left breast examination is unremarkable. The client calls to report her findings to the clinical nurse because this is not her typical result. What action should the nurse take next? a. Refer the client to an oncologist because the results sound suspicious. b. Ask the client to come in for an office visit so that the findings can be validated but tell her that this information is within the normal range of presentation. c. Have the client wear a tight-fitting bra and tell her that the tenderness is associated with ovulation and will pass. d. Have the client repeat the self-breast exam in 2 weeks and call back with findings to provide a basis for comparison.
The nurse plans to include nonpharmacologic pain management strategies when caring for patients experiencing pain. Which of the following rationales best explains why massage is helpful for pain relief?
1. Skin stimulation inhibits transmission of impulses from the spinal cord to the brain. 2. Vasoconstriction due to heat application prevents prostaglandin release. 3. Friction from massage causes heat in the area, which distracts the patient from the pain. 4. Massage will mask the symptoms of pain during the massage and for several hours after.
A newborn is challenged to maintain an adequate body temperature. If a baby is placed too close to a cold air vent, the nurse can assume that the infant will lose heat by which mechanism?
A) Conduction B) Convection C) Radiation D) Evaporation