A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused.The patient complains of "just blowing up" and has peripheral edema and shortness of breath.Which assessment should the nurse complete first?

Question

Quizplus · Accepted Answer

Increases in extracellular fluid (ECF)can lead to swelling of cells in the central nervous system,initially causing confusion,which may progress to coma or seizures.Although skin turgor,capillary refill,and heart sounds also may be affected by increases in ECF,these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

A Nurse Is Assessing a Newly Admitted Patient with Chronic