Author Question: The nurse working on the heart failure unit knows that teaching an older female patient with newly ... (Read 89 times)

Lisaclaire · **on:** Jun 25, 2018

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that

a. she will take furosemide (Lasix) every day at bedtime.
b. the nitroglycerin patch is applied when any chest pain develops.
c. she will call the clinic if her weight goes from 124 to 128 pounds in a week.
d. an additional pillow can help her sleep if she is feeling short of breath at night.

Question 2

During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed.

Based on these data, the best nursing diagnosis for the patient is
a. activity intolerance related to fatigue.
b. disturbed body image related to weight gain.
c. impaired skin integrity related to ankle edema.
d. impaired gas exchange related to dyspnea on exertion.

lucas dlamini · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an as needed basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed.

Answer to Question 2

ANS: A
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.