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The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

A.

The nurse will encourage the client to walk thirty minutes every day.

B.

The client's family will state signs and symptoms about the disease.

C.

The client's blood pressure readings will be less than 160/90 mm Hg.

D.

The client's daily blood pressure will be less than 140/80 mm Hg this month.

Answer and Explanation

The Correct Answer is D

A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.  

 

B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.  

 

C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.  

 

D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall cardiovascular health. This target is aligned with current clinical guidelines for hypertension management.  


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Correct Answer is B

Explanation

A. Removing ink marks can lead to difficulty in accurately targeting the radiation area, so the marks should be left in place until the treatment course is complete.

B. Protecting the skin from sunlight exposure is crucial, as the irradiated skin is more sensitive and at increased risk for sunburn. This recommendation helps to prevent further irritation and damage to the skin during and after treatment.

C. While moisturizing lotions can be beneficial for maintaining skin integrity, they should be used cautiously and only if prescribed by the healthcare provider, as some products may cause irritation.

D. The skin inside the radiation portal site should be washed gently with mild soap and water to keep it clean; avoiding washing is not advisable as it can lead to skin breakdown.

Correct Answer is D

Explanation

A. While bowel sounds can indicate gastrointestinal activity, they do not directly correlate with pain management or the underlying cause of abdominal discomfort in chronic pancreatitis.

B. The level and amount of physical activity may impact overall well-being but are less directly related to the management of abdominal pain from pancreatitis.

C. The color and consistency of feces can provide some information regarding pancreatic function and fat absorption but is not the most immediate factor affecting pain management.

D. Understanding the client’s eating patterns, including food triggers and timing, is crucial because certain foods can exacerbate abdominal pain in chronic pancreatitis. Dietary adjustments can significantly help manage symptoms and improve quality of life.

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