Which of the ff symptoms is observed in the client with Right Sided Heart Failure?

Correct Answer: A

Rationale: Rationale: Right-sided heart failure leads to fluid backup in the body causing dependent pitting edema due to fluid accumulation in the lower extremities. Orthopnea and exertional dyspnea are typically seen in left-sided heart failure. Hemoptysis is associated with conditions like pulmonary embolism or lung cancer, not right-sided heart failure. Therefore, the correct answer is A as it directly correlates with the symptoms of right-sided heart failure.

Correct Answer: A

Rationale: The correct answer is A: Otorrhea. Otorrhea refers to the discharge of fluid from the ear, indicating an abnormal finding of ear drainage. This term specifically describes the symptom of ear drainage, making it the most appropriate choice for documenting this finding. Otalgia (choice B) refers to ear pain, ototoxic (choice C) refers to substances that are harmful to the ear, and tinnitus (choice D) refers to ringing in the ears, none of which accurately describe ear drainage. Therefore, the correct choice is A as it specifically addresses the symptom of ear drainage.

Correct Answer: D

Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT. Rationale: A) RBC count: AZT can cause anemia, not specifically affecting the RBC count. B) Serum calcium: AZT does not typically affect calcium levels. C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: D

Rationale: The correct answer is D because morphine helps in acute pulmonary edema by decreasing peripheral resistance, pulmonary capillary pressure, and transudation of fluid. Morphine causes vasodilation, reducing peripheral resistance, which helps redistribute blood flow to the periphery. It also reduces pulmonary capillary pressure by decreasing preload and afterload, leading to decreased fluid transudation into the alveoli. Choices A, B, and C individually do not cover all the effects of morphine in acute pulmonary edema, making them incorrect.

Correct Answer: B

Rationale: The correct answer is B: Obesity. Obesity is a well-established risk factor for developing type 2 diabetes mellitus due to the increased resistance of body cells to insulin. This leads to elevated blood sugar levels. Hypotension (A) is low blood pressure and is not typically associated with type 2 diabetes. Kidney dysfunction (C) is a complication of diabetes but not a direct correlation. Sex (D) does not have a direct link to the development of type 2 diabetes. Therefore, the most likely correlation is with obesity due to its impact on insulin resistance.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: B

Rationale: The correct answer is B: Probenecid (Benemid). Probenecid can increase methotrexate levels, leading to potential toxicity. Methotrexate is primarily eliminated by the kidneys, and Probenecid inhibits renal tubular secretion, causing methotrexate levels to rise. Digoxin (A), theophylline (C), and famotidine (D) do not have significant interactions with methotrexate. In summary, Probenecid is the correct answer as it can increase methotrexate levels through renal tubular secretion inhibition, while the other choices do not have a significant interaction with methotrexate.

Correct Answer: A

Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting. Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.