A client with congestive heart failure reports waking up at night with sudden breathlessness and feeling the need to sit upright to breathe comfortably. The nurse should document this symptom as:
Orthopnea
Paroxysmal nocturnal dyspnea
Peripheral edema
Tachypnea
The Correct Answer is B
A) This choice is incorrect because orthopnea is a different symptom where the client experiences difficulty breathing while lying flat and finds relief by sitting upright or standing.
B) This choice is correct. Paroxysmal nocturnal dyspnea is characterized by sudden breathlessness that awakens the client from sleep, usually 1-2 hours after falling asleep. The client may feel the need to sit upright or dangle the legs to breathe comfortably.
C) This choice is incorrect because peripheral edema refers to swelling in the legs, ankles, and feet, which is a common symptom of congestive heart failure but does not match the client's reported symptom.
D) This choice is incorrect because tachypnea is rapid breathing and is not specifically related to the client's nighttime symptom of sudden breathlessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This choice is incorrect because a body mass index (BMI) of 22 kg/m² is within the normal range and is not directly associated with the development of congestive heart failure in this scenario.
B) This choice is incorrect because a blood pressure of 120/80 mmHg is within the normal range and does not indicate a direct precipitating factor for congestive heart failure in this case.
C) This choice is incorrect because a fasting blood glucose level of 90 mg/dL is within the normal range and is not directly associated with the development of congestive heart failure in this scenario.
D) This choice is correct. A serum cholesterol level of 240 mg/dL indicates high cholesterol, which is a risk factor for coronary artery disease. Coronary artery disease is a leading cause of congestive heart failure and may have contributed to the client's condition.
Correct Answer is B
Explanation
A) This choice is incorrect because restricting all physical activity is not recommended for clients with congestive heart failure. Regular, moderate exercise can be beneficial for heart health when appropriately prescribed by the healthcare provider.
B) This choice is correct. Regularly weighing themselves, ideally daily, and reporting sudden weight gain to the healthcare provider is essential for clients with congestive heart failure. Sudden weight gain may indicate fluid retention, a worsening of heart failure, or medication non-compliance.
C) This choice is incorrect because a high-sodium diet can worsen fluid retention and exacerbate congestive heart failure symptoms. The client should follow a low-sodium diet to manage fluid balance.
D) This choice is incorrect because taking prescribed medications only when symptoms worsen is not appropriate for congestive heart failure management. The client should take prescribed medications as directed by the healthcare provider, even when feeling well, to prevent symptom exacerbation and improve heart function.
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