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During a visit to a patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2 kg weight gain, and complains of 'feeling too tired to do anything.' Based on these data, which of the following is the best nursing diagnosis for the patient?
- A. Activity intolerance related to physical deconditioning
- B. Disturbed body image related to alteration in self-perception
- C. Impaired skin integrity related to alteration in fluid volume (peripheral edema)
- D. Ineffective breathing pattern related to respiratory muscle fatigue
Correct Answer: A
Rationale: The patient's statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.
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The nurse is caring for an older-adult patient with heart failure and learns that the patient lives alone and sometimes confuses the 'water pill' with the 'heart pill.' When planning for the patient's discharge the nurse will facilitate which of the following actions?
- A. Transfer to a dementia care service
- B. Referral to a home health care agency
- C. Placement in a long-term care facility
- D. Arrangements for around-the-clock care
Correct Answer: B
Rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term care, or around-the-clock home care.
Which of the following patients is less likely to enroll in a cardiac rehabilitation program?
- A. A 64-year-old male who has diabetes
- B. A 51-year-old male who has a same-sex partner
- C. A 52-year-old single female
- D. A 39-year-old male with two children
Correct Answer: C
Rationale: Women are 36% less likely to enroll in cardiac rehabilitation programs.
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which of the following actions should the nurse take first?
- A. Palpate the abdomen.
- B. Assess the orientation.
- C. Check the capillary refill.
- D. Auscultate the lung sounds.
Correct Answer: D
Rationale: This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac or respiratory arrest. The other assessments will provide useful data about the patient's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.
A patient with heart failure has a new order for lisinopril 10 mg PO. After administering the first dose and teaching the patient about lisinopril, which statement by the patient indicates that teaching has been effective?
- A. I will call for help when I need to get up to use the bathroom.
- B. I will be sure to take the medication after eating something.
- C. I will need to include more high-potassium foods in my diet.
- D. I will expect to feel more short of breath for the next few days.
Correct Answer: A
Rationale: Lisinopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparing, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is not an expected effect of ACE inhibitors, which are best absorbed when taken an hour before eating.
The nurse is caring for a patient in the intensive care unit with acute decompensated heart failure (ADHF) who has symptoms of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been prescribed for the patient. Which of the following actions should the nurse implement first?
- A. Give IV diazepam 2.5 mg
- B. Administer IV morphine sulphate 2 mg
- C. Increase nitroglycerin infusion by 5 mcg/min.
- D. Increase dopamine infusion by 2 mcg/kg/min.
Correct Answer: B
Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.