Review
,The nurse is caring for a client with scleroderma.
Which assessment finding indicates the most
serious complication of the disease and requires
priority intervention?
1. Abrupt- onset hypertension and headache
2. Blue and cold fingertips
3. Dry cough and exertional dyspnea
4. Heartburn and difficulty swallowing
,The home care nurse visits the house of an
elderly client. Which assessment finding requires
immediate intervention?
1. The client cannot remember what was
done yesterday
2. The client has a painful red area on the buttocks
3. The client has new dependent edema of the feet
4. The client has strong, foul smelling urine
, The nurse is discharging a client hospitalized for a new
diagnosis of heart failure. The discharge medications
include lisinopril 10 mg and spironolactone 25 mg. The
client has also been started on a 2000 mg low-sodium diet.
Which statement by the client indicates teaching on
discharge instructions has been effective?
1. “I will be sure to take my medications before bedtime
2. I will eat more fresh fruits like bananas and oranges
3. I will limit my intake of cheeses, breads, and canned foods
4. I will use a salt substitute to season my food