Author Question: A patient with heart failure has BP 120/60, HR 64, R 18, T 97.6F, coarse crackles bilaterally, and ... (Read 127 times)

saraeharris · **on:** Jul 23, 2018

A patient with heart failure has BP 120/60, HR 64, R 18, T 97.6F, coarse crackles bilaterally, and 3+ edema to the lower extremities. An appropriate nursing diagnosis for this patient is:

a. Impaired gas exchange
b. Excess Fluid Volume
c. Ineffective Tissue Perfusion
d. Deficient Knowledge

Question 2

The nurse is performing a sexual assessment on a newly admitted married 60-year-old female patient. Which question should the nurse omit from the nursing assessment?

a. Are you sexually active?
b. How often do you have sexual intercourse?
c. Do you experience any discomfort during sex?
d. What method of birth control are you currently using?

randomguy133 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

B
Excess Fluid Volume is an appropriate nursing diagnosis for someone demonstrating increased isotonic fluid retention, as demonstrated by adventitious breath sounds (crackles bilaterally) and edema. There is no indication that this patient is experiencing impaired gas exchange or inefficient tissue perfusion based on the information provided. Although the patient may have knowledge deficit, this is not a priority at this time.

Answer to Question 2

D
A woman aged 60 is not capable of becoming pregnant, so questions about birth control are not needed, but use of barrier methods to prevent STIs may be asked when appropriate. People aged 60 and older may or may not be sexually active. Marriage is not an indicator of sexual activity because some married people are not sexually active. Asking about frequency of sexual activity can be an indicator of health, exercise tolerance, and other important factors, so should be asked of this patient. Questions about discomfort during sex are important because patients may not bring up the subject if not asked directly.