The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes during the night frightened and short of breath. Based on this data, what is the client experiencing?

Correct Answer: B

Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.

Correct Answer: A

Rationale: In the case of an adult client experiencing paroxysmal supraventricular tachycardia, the appropriate nursing intervention of initiating oxygen therapy is crucial. This is because adequate oxygenation helps optimize cardiac function and tissue perfusion during episodes of tachycardia. Oxygen therapy supports the myocardium and helps prevent complications associated with increased heart rate. Preparing for cardioversion is not indicated in this scenario as paroxysmal supraventricular tachycardia does not typically require cardioversion unless it is hemodynamically unstable. Beginning anticoagulation therapy is also not necessary for this condition unless there are other indications present. Administering intravenous adenosine is a treatment option for paroxysmal supraventricular tachycardia; however, it is usually done under medical supervision and not a primary nursing intervention. From an educational perspective, it is important for nurses to understand the rationale behind each intervention to provide safe and effective care to patients. Recognizing the appropriate interventions based on the specific condition helps nurses prioritize care and promote positive patient outcomes. This case highlights the significance of critical thinking and clinical reasoning in nursing practice, emphasizing the importance of evidence-based interventions tailored to individual patient needs.

Correct Answer: B

Rationale: The brown pigmentation of the lower extremities in clients with venous stasis is primarily caused by the breakdown of red blood cells in the congested tissues. When there is venous stasis, the blood circulation is impaired, leading to a backup of blood in the lower extremities. This stagnant blood contains hemosiderin, a byproduct of red blood cell breakdown. Over time, the hemosiderin deposits in the tissues, causing the characteristic brown discoloration seen in conditions such as chronic venous insufficiency. This process is known as hemosiderin deposition and is a common consequence of venous stasis.

Correct Answer: C

Rationale: In a client experiencing hypovolemic shock, the priority collaborative intervention is to provide replacement of volume to improve tissue perfusion and restore organ function. Hypovolemic shock is characterized by a significant loss of intravascular volume, leading to inadequate tissue perfusion and oxygenation. Beta-adrenergic blockers can exacerbate hypovolemic shock by further decreasing cardiac output and blood pressure. Therefore, the immediate priority is to address the hypovolemia by providing volume replacement through fluid resuscitation to stabilize the patient before assessing the cause of bleeding or establishing invasive cardiac monitoring. Administering analgesics for pain control is important but not the priority in this situation.

Correct Answer: B

Rationale: After a stroke, sensory-perceptual changes such as impaired proprioception, altered sensation, and decreased awareness of the affected side can increase the client's risk for injury. These changes can result in difficulties with balance, coordination, and spatial awareness, making the individual more prone to falls and accidents. It is important to implement safety measures and interventions to minimize the risk of injury in these clients, such as providing a structured environment, using assistive devices, and encouraging regular monitoring and assistance as needed.