A patient asks the nurse what her diagnosis of heart failure means. Which of the ff. is the nurse's best response?

Correct Answer: D

Rationale: The nurse's best response is D, "Your heart is not an efficient pump." Heart failure is a condition where the heart is unable to pump blood efficiently, leading to a decrease in the heart's ability to supply the body with oxygen and nutrients. This can result in symptoms such as shortness of breath, fatigue, and fluid retention. It is important for the patient to understand that heart failure does not mean the heart stops or has an area of dead muscle, but rather it is a condition where the heart is not able to function properly as a pump.

Correct Answer: B

Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.

Correct Answer: A

Rationale: Providing clear liquids only until the patient can swallow solid foods is not recommended as it restricts the patient's diet unnecessarily. In the case of difficulty swallowing after a stroke, it is important to modify the food consistency and provide appropriate techniques to support safe swallowing. Limiting the patient to clear liquids only could lead to inadequate nutrition and hydration. Instead, it is important to modify the diet consistency and use strategies such as altering the food presentation, having the patient swallow twice after each bite, placing food on the unaffected side of the mouth, and checking for pocketing of food to help prevent aspiration.

Correct Answer: C

Rationale: Nerves from the thoracic cord supply the trunk of the body. The thoracic spinal cord region is responsible for supplying nerves to the chest, abdomen, and back—the areas that make up the trunk of the body. Each level of the thoracic spinal cord is associated with specific nerves that innervate different areas of the trunk, including the intercostal muscles, abdominal muscles, and other structures. Therefore, the trunk is the part of the body supplied by nerves from the thoracic cord.

Correct Answer: C

Rationale: ACTH (Adrenocorticotropic hormone) might be ordered to help control symptoms of multiple sclerosis and possibly induce a remission. ACTH is sometimes used as a treatment option for multiple sclerosis due to its anti-inflammatory properties. It can help reduce inflammation in the central nervous system and, in some cases, lead to a decrease in symptoms and possibly induce a remission. However, it is important to note that ACTH is not commonly used as a first-line treatment for multiple sclerosis and is usually reserved for cases that are refractory to other medications.