The nurse is assessing a patient diagnosed with heart failure. Which of the following assessment findings would be a priority for the nurse to gather more information?
1. a 3-4 pound weight gain in 24 hours
2. the need to space out activities
3. a resting heart rate of 62 beats per minute
4. needing to sleep in a recliner
1
Rationale: A weight gain of 3 to 4 pounds in 24 hours indicates an increase in fluid volume status and should be further evaluated. The other assessment findings could be seen in any patient diagnosed with heart failure and do not necessarily signify a worsening condition.
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A) Keep a television on in the bedroom. B) Provide white noise with a fan. C) Play soft music through the night. D) Play a talk radio station.
A nurse is caring for four clients. Which client is most likely to have continuous amnesia?
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A resident has problems finding her room, the bathroom, the dining room, and so on. Which of the following might help her?
a. Telling her the date, the time, and the place b. Showing her where things are c. Picture signs d. Keeping personal items where she can see them