The nurse is assessing a patient diagnosed with dilated cardiomyopathy for progression of the disease. The nurse would focus questioning on which most common symptom?
1. Confusion
2. Cyanosis
3. Dyspnea
4. Peripheral edema
3
Rationale 1: Confusion may be present but is not the most common clinical manifestation.
Rationale 2: Cyanosis may be present but is not the most common manifestation.
Rationale 3: Dyspnea occurs because the enlarged heart compresses the bronchioles, thus diminishing the amount of oxygen entering and leaving the lungs. Additionally, blood backs up into the lungs due to heart failure, which is common in dilated cardiomyopathy.
Rationale 4: Peripheral edema may occur but is not the most common clinical manifestation.
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A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe?
A) It allows for full expansion of the lungs within the thoracic cavity. B) It prevents the lungs from collapsing within the thoracic cavity. C) It limits lung expansion within the thoracic cavity. D) It lubricates the movement of the thorax and lungs.
Which nursing interventions are appropriate for a a patient with bulimia nervosa? Select all that apply
1. Monitoring trips to the bathroom 2. Providing emotional support during mealtimes 3. Reviewing events and feelings prior to an episode 4. Providing negative feedback to reframe feelings of purging 5. Encouraging engagement with previously enjoyed activities and experiences
The nurse caring for a 2-day postoperative colostomy patient should report immediately if a stoma is assessed as:
1. beefy and red. 2. having swelling. 3. having a small amount of bleeding around it. 4. blue-tinged.
A client with otitis media is ordered to receive amoxicillin (Amoxil). The client discloses to the nurse that she is allergic to penicillin. What is the highest priority action on the part of the nurse?
a. Notify the healthcare provider that the client is allergic to penicillin. b. Encourage the client to take the dose under close monitoring. c. Administer half of the amoxicillin dose under supervision. d. Report the amoxicillin order to the supervisor.