A nurse is caring for a client with a history of congestive heart failure at risk for development of fluid volume excess. The nurse should monitor for
... [Show More] which of the following that is a manifestation of left sided heart failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night - Dyspnea with a cough that is worse at night
Dyspnea with a cough that is worse at night is an indication of left-sided heart failure. Left-sided heart failure causes blood to back up in the heart and lungs with decreased distribution of blood throughout the body.
Which client problem should receive highest priority when a client is admitted with an acute exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety - Impaired physical mobility
When setting priorities for nursing care, physiological needs should be addressed first according to Maslow's Hierarchy of Needs. Reducing the client's pain will help with other needs, such as hygiene and grooming.
A nurse is caring for a client with hypoparathyroidism. Because of the potential electrolyte disturbance associated with this diagnosis, the nurse should observe the client for evidence of which of the following?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss - Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased serum calcium levels), which may cause tetany. Involuntary muscle spasms are a common symptom associated with hypothyroidism.
A client with glaucoma is admitted for surgery the following day. The client is to continue treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day. While instilling this medication, an appropriate nursing action is which of the following?
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead.
Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds after instillation. - Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to the puncta for 1 to 2 min to prevent loss of medication into the nasal lacrimal duct and into the systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the nurse should instruct the client to do which of the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures.
Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot. [Show Less]