The nurse is reviewing assessment data for a client with a ...

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The nurse is reviewing assessment data for a client with a history of congestive heart failure who was admitted for shortness of breath. The client reported not having enough money to purchase medications.
 
  Which of the following nursing diagnoses will be of the greatest initial importance when planning care? 1. Activity Intolerance related to shortness of breath
   2. Fatigue related to shortness of breath
   3. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications
   4. Excess Fluid Volume related to shortness of breath

Question 2

A child with congestive heart failure (CHF) has been admitted. While assessing this client, the nurse would find which of the following?
 
  1. Weight loss
   2. Bradycardia
   3. Tachycardia
   4. Increased blood pressure

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Answer to Question 1

4. Excess Fluid Volume related to shortness of breath

Rationale:
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 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

3. Tachycardia

Rationale:
Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

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Gracias!

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