A patient with heart failure is experiencing increased fatigue and has a weight gain of 1 kg. The nurse realizes this patient is demonstrating signs of:
1. Systemic deterioration
2. Pulmonary deterioration
3. Cardiac deterioration
4. Renal deterioration
1
Rationale 1: Signs of systemic deterioration include weight gain and fatigue.
Rationale 2: Weight gain and fatigue are not signs of pulmonary deterioration.
Rationale 3: Weight gain and fatigue are not signs of cardiac deterioration.
Rationale 4: The renal status is not specifically assessed in the patient with heart failure.
You might also like to view...
The mission statement of an organization serves to:
a. establish long range goals b. articulate where the organization is going c. direct decision making about the organization d. develop a strategic plan
The nurse is helping a patient work through the process of recovering from a communicable neurological disease. What actions will the nurse take to help this patient heal? (Select all that apply.)
A) Teaching ways to overcome temporary disabilities B) Guiding to make healthy life choices going forward C) Modeling healthy behaviors for the patient to emulate D) Recommending others to take care of the patient at home E) Encouraging following the treatment plan to improve health
The nurse is admitting an 8-year-old Vietnamese child who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic, and denies pain
The most appropriate initial action by the nurse is to: 1. Use the FLACC scale to determine the child's pain level. 2. Tell the child to ring the call bell if the leg starts hurting. 3. Administer pain medication now and continue on a regular basis. 4. Ask the child's parents to notify the nurse if the child complains of pain.
When interpreting laboratory data, you would expect to see the following in a patient with Anemia of Chronic Disease (ACD)
A. Hemoglobin <12 g/dl, Mean Corpuscular Volume (MCV) decreased, Mean Corpuscular Hemoglobin (MCH) decreased B. Hemoglobin >12 g/dl, Mean Corpuscular Volume (MCV) increased, Mean Corpuscular Hemoglobin (MCH) increased C. Hemoglobin <12 g/dl, Mean Corpuscular Volume (MCV) normal, Mean Corpuscular Hemoglobin (MCH) normal D. Hemoglobin >12 g/dl, Mean Corpuscular Volume (MCV) decreased, Mean Corpuscular Hemoglobin (MCH) increased