During hospitalization for congestive heart failure (CHF), a ...

[Zoey63294]

During hospitalization for congestive heart failure (CHF), a client awakens during the night frightened and short of breath. Based on this data, what is the client experiencing?
 
  A) Cardiomyopathy
  B) Paroxysmal nocturnal dyspnea
  C) High-output failure
  D) Multisystem heart failure

Question 2

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Tissue Perfusion. Which action is inappropriate for this nursing diagnosis?
 
  A) Monitor the client's level of consciousness and mental status.
  B) Elevate the client's knees on the bed or with a pillow.
  C) Minimize the use of tape on the client's skin.
  D) Assess extremity pulses, warmth, and capillary refill.

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Answer to Question 1

Answer: B

Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.

Answer to Question 2

Answer: B

Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis.

[Zoey63294]

Correct answers!

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