Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?

Correct Answer: B

Rationale: Dyspnea on exertion is often identified as the earliest symptom of heart failure in many older clients. This symptom occurs due to the heart's inability to pump blood efficiently, leading to a buildup of fluid in the lungs. As a result, individuals may experience shortness of breath when engaging in physical activity or even at rest. Monitoring for dyspnea on exertion can aid in the early detection and management of heart failure in older clients. Other symptoms, such as increased urine output, swollen joints, and nausea/vomiting, may also occur in heart failure, but dyspnea on exertion is typically considered one of the earliest signs to manifest.

Correct Answer: C

Rationale: The best response by the nurse is to explain that someone will assist the patient as long as she is in the rehabilitation facility. This is important for ensuring the safety of the patient, especially considering her condition with left-sided hemiparesis resulting from a subarachnoid hemorrhage. While encouraging independence is important in rehabilitation, it should not compromise the patient's safety. The nurse should prioritize the patient's well-being and provide necessary assistance to prevent any potential falls or injuries during ambulation.aising the risk of falling or getting injured.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D, "All are correct." Let's break down each option to understand why D is the most appropriate choice. A) Symptoms include salivation, cramping, nausea, vomiting, and diarrhea: This statement is true because these are common symptoms of food poisoning caused by ingestion of contaminated food. B) Foods that are handled and allowed to remain without refrigeration before eaten are most dangerous: This statement is also accurate as improper handling and storage of food can lead to bacterial growth and contamination, increasing the risk of food poisoning. C) Cooking will destroy the organism and stop production of enterotoxin: This statement is true as proper cooking temperatures can kill harmful bacteria and prevent the production of toxins that cause food poisoning. Selecting option D is correct because all the statements are accurate and relevant to the topic of food poisoning. Understanding these facts is crucial for healthcare professionals, especially nurses, who need to be well-versed in food safety practices to prevent and manage cases of foodborne illnesses in pediatric patients. By choosing option D, nurses can ensure proper assessment, intervention, and patient education when dealing with food poisoning cases.

Correct Answer: C

Rationale: Patients with Guillain-Barre Syndrome are at risk for respiratory complications due to muscle weakness and paralysis, particularly affecting the respiratory muscles. Monitoring arterial blood gas (ABG) levels is crucial in assessing respiratory function and detecting respiratory failure early in these patients. ABG levels provide information on oxygenation, ventilation, and acid-base balance, which are essential parameters to monitor closely in patients with Guillain-Barre Syndrome to prevent respiratory compromise and potential respiratory failure. Regular ABG monitoring helps healthcare providers intervene promptly if respiratory abnormalities develop, ensuring timely treatment and preventing serious complications.

Correct Answer: C

Rationale: It is important to instruct the client's family to check with the physician or pharmacist before crushing or breaking tablets, or opening capsules for a client with impaired swallowing who needs to take solid medication. Many medications have special formulations or coating that may alter their effectiveness if not taken whole. Consulting with a healthcare professional ensures that the medication remains safe and effective when modifying its form for a client with difficulty swallowing. Mixing the medication with food (option A) may also alter its effectiveness, so it is crucial to seek guidance before making any changes to the medication form. Using the liquid form of the medication (option B) may be a suitable alternative if available; however, this decision should also be discussed and approved by the healthcare provider. Performing ROM exercises after medication administration (option D) is unrelated to addressing the issue of impaired swallowing and medication administration.