During an assessment, a client with congestive heart failure ...

[jake]

During an assessment, a client with congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care?
 
  A) Excess Fluid Volume related to shortness of breath
  B) Ineffective Family Management of Therapeutic Regime related to inability to purchase medications
  C) Fatigue related to shortness of breath
  D) Activity Intolerance related to shortness of breath

Question 2

The nurse is caring for a child with heart failure (CHF). Which clinical manifestations does the nurse anticipate when assessing this child?
 
  Select all that apply.
  A) Shortness of breath
  B) Weight loss
  C) Bradycardia
  D) Tachycardia
  E) Increased blood pressure

[Ptupou85]

Answer to Question 1

Answer: A

The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.

Answer to Question 2

Answer: A, D

Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and can indicate impending cardiac arrest, but is not a typical assessment finding in a client with CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

[jake]

Gracias!

[T4T]

TYSM