A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client?

Correct Answer: B

Rationale: The client with cardiomyopathy may experience decreased cardiac output, which is a common manifestation of this condition. Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. Reduced cardiac output means that less blood is being pumped out by the heart with each beat, leading to symptoms such as fatigue, weakness, and the need to rest between activities. This is why the client is experiencing the need to rest between activities during the day.

Correct Answer: C

Rationale: Swelling in one leg with edema is a classic sign of deep venous thrombosis (DVT). DVT occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs. This can lead to swelling in the affected leg due to the impaired venous return caused by the blood clot. It is important for the nurse to recognize this sign because if left untreated, DVT can lead to serious complications such as pulmonary embolism. Therefore, the nurse should further assess the client and notify the healthcare provider for appropriate management.

Correct Answer: C

Rationale: Disseminated intravascular coagulation (DIC) is a condition characterized by widespread activation of clotting factors throughout the body, leading to both excessive clot formation and consumption of clotting factors. As a result, one of the common features of DIC is a decreased level of fibrinogen, which is an essential protein for blood clot formation. In DIC, fibrinogen is consumed in the formation of multiple small blood clots throughout the circulation, causing a decrease in its levels. This decrease in fibrinogen can contribute to the increased risk of bleeding that is seen in DIC. Therefore, a decreased fibrinogen level is a characteristic laboratory finding in DIC.

Correct Answer: B

Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.

Correct Answer: B

Rationale: When caring for a laboring client diagnosed with preeclampsia, it is important to be mindful of certain considerations to ensure the safety and well-being of both the mother and the baby. Placing the client in left lateral position when she feels the urge to push is crucial in cases of preeclampsia as it helps to optimize maternal and fetal oxygenation. This position can help improve blood flow to the placenta and reduce the risk of decreased perfusion due to the elevated blood pressure associated with preeclampsia. By maintaining the client in the left lateral position during pushing, it can help prevent potential complications and support better outcomes for both the mother and baby.