Author Question: The patient weighs 450 lbs (204.5 kg) and reports shortness of breath with any exertion. The health ... (Read 75 times)

ghost! · **on:** Jul 22, 2018

The patient weighs 450 lbs (204.5 kg) and reports shortness of breath with any exertion. The health care provider has recommended beginning an exercise program.

The patient states that she can hardly get out of bed and just cannot do anything around the house. Which nursing diagnosis will the nurse add to the care plan?
a. Activity intolerance related to excessive weight
b. Impaired physical mobility related to bed rest
c. Imbalanced nutrition: less than body requirements
d. Impaired gas exchange related to shortness of breath

Question 2

The patient reports being tired and weak and lacks energy. Upon assessment, the nurse finds that patient has gained weight, and blood pressure and pulse are elevated after climbing stairs. Which nursing diagnosis will the nurse add to the care plan?

a. Fatigue
b. Ineffective coping
c. Activity intolerance
d. Decreased cardiac output

SeanoH09 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A
In this case, activity intolerance is related to the patient's excessive weight. The patient is not on bed rest although claims that it is difficult to get out of bed, making this diagnosis inappropriate. Shortness of breath is a symptom, not a cause, of Impaired gas exchange, making this nursing diagnosis ineffective. The patient certainly has an imbalance of nutrition, but it is more than body requirements (obesity).

Answer to Question 2

ANS: C
You consider nursing diagnoses of Activity intolerance or Fatigue in a patient who reports being tired and weak. Further review of assessed defining characteristics (e.g., abnormal heart rate and verbal report of weakness and the assessment findings occurring during the activity of climbing the stairs) leads to the definitive diagnosis (Activity intolerance). There is no data to support ineffective coping or decreased cardiac output.