What is a primary symptom of left-sided heart failure?

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Question 1 of 9

What is a primary symptom of left-sided heart failure?

Correct Answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.

Question 2 of 9

What is a primary symptom of left-sided heart failure?

Correct Answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.

Question 3 of 9

A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?

Correct Answer: C

Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.

Question 4 of 9

What are the risk factors for developing hypertension?

Correct Answer: A

Rationale: The correct answer is A: High sodium diet and lack of physical activity. These are established risk factors for developing hypertension as they contribute to elevated blood pressure. Choice B, low potassium intake and excessive alcohol consumption, may also impact blood pressure but are not as strongly associated with hypertension as high sodium intake and lack of physical activity. Choice C, frequent exercise and a low cholesterol diet, are actually beneficial for reducing the risk of hypertension. Choice D, smoking and family history, are more closely linked to other health conditions such as cardiovascular diseases, rather than being primary risk factors for hypertension.

Question 5 of 9

The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

Correct Answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

Question 6 of 9

A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

Correct Answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

Question 7 of 9

A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?

Correct Answer: B

Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.

Question 8 of 9

A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Correct Answer: B

Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.

Question 9 of 9

What are the nursing interventions for a patient with hypokalemia?

Correct Answer: A

Rationale: The correct intervention for a patient with hypokalemia is to administer potassium supplements and monitor the ECG. Potassium supplements help correct the low potassium levels in the body, while ECG monitoring is essential to detect any cardiac arrhythmias associated with hypokalemia. Choice B is incorrect because a high-sodium diet would worsen hypokalemia by further depleting potassium levels. Choice C is incorrect as it only focuses on monitoring symptoms and providing dietary education, but does not address the immediate need to correct potassium levels. Choice D is also incorrect as administering diuretics would exacerbate hypokalemia by increasing potassium loss.

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