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Free NCLEX-RN Exam Braindumps (page: 109)

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A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:

  1. A diet too high in calories and saturated fat
  2. Decreasing cardiac output
  3. Decreasing renal function
  4. Development of diabetes insipidus

Answer(s): B

Explanation:

(A) Increased calories may result in weight gain, but there is no indication in this question that this man's diet has changed in a way that would result in increased calories. (B) Decreasing cardiac output stimulates the renin-angiotensin-aldosterone cycle and results in fluid retention, which is reflected by weight gain. (C) Decreasing renal function may result in fluid retention, but this question gives no indication that this man has any renal problems. (D) Profound diuresis occurs with diabetes insipidus, which results in weight loss.



A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:

  1. A diet too high in calories and saturated fat
  2. Decreasing cardiac output
  3. Decreasing renal function
  4. Development of diabetes insipidus

Answer(s): B

Explanation:

(A) Increased calories may result in weight gain, but there is no indication in this question that this man's diet has changed in a way that would result in increased calories. (B) Decreasing cardiac output stimulates the renin-angiotensin-aldosterone cycle and results in fluid retention, which is reflected by weight gain. (C) Decreasing renal function may result in fluid retention, but this question gives no indication that this man has any renal problems. (D) Profound diuresis occurs with diabetes insipidus, which results in weight loss.



What is the appropriate nursing action for a child with increased intracranial pressure?

  1. Head of bed elevated 45 degrees with child's head maintained in a neutral position
  2. Child lying flat
  3. Head turned to side
  4. Frequent visitation for stimulation

Answer(s): A

Explanation:

(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.



What is the appropriate nursing action for a child with increased intracranial pressure?

  1. Head of bed elevated 45 degrees with child's head maintained in a neutral position
  2. Child lying flat
  3. Head turned to side
  4. Frequent visitation for stimulation

Answer(s): A

Explanation:

(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.






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