A nurse admits an older patient to the emergency room with reports of shortness of breath on exertion and a productive cough.
The nurse reviews the patient's current medications and the patient says, “I take one pink pill every morning.”. The nurse asks the name of the drug and the patient says she doesn’t know.
The patient cannot supply the name of the drug or the purpose of taking it either.
This happens with four other medications the patient says she takes.
What is an appropriate nursing diagnosis for this patient?

Choice A rationale

Heart failure occurs when the heart muscle cannot pump blood effectively, leading to a backup of blood and fluid buildup in the lungs, legs, and other parts of the body. This explanation is accurate and helps the patient understand the nature of their condition.

Choice B rationale

Reduced oncotic pressure due to increased protein levels is not a primary factor in heart failure. Heart failure is related to the heart’s inability to pump effectively, not protein levels affecting oncotic pressure.

Choice C rationale

Hydrostatic pressure pushing fluids out of the capillaries is not directly related to heart failure. In heart failure, the issue lies in the heart’s inability to pump blood efficiently, leading to fluid buildup rather than fluid being pushed out of capillaries.

Choice D rationale

The decrease in venous pressure from the backup of blood does not cause heart failure. Heart failure results from the heart’s inability to pump blood effectively, leading to increased pressure and fluid buildup, not a decrease in venous pressure.

Choice A rationale

Coagulation studies assess the blood's ability to clot and are not directly related to the monitoring of phenytoin therapy. These tests are more relevant for patients with bleeding disorders or those on anticoagulant therapy.

Choice B rationale

Serum electrolytes, including levels of sodium, potassium, and calcium, are important for overall health but are not specifically indicative of phenytoin levels. Phenytoin may affect calcium metabolism, but it is not the primary focus for routine monitoring.

Choice C rationale

Renal function tests are crucial for assessing kidney function but do not directly monitor phenytoin therapy. Phenytoin is primarily metabolized in the liver, making liver function tests more relevant.

Choice D rationale

Blood glucose levels should be monitored in patients taking phenytoin as the drug can cause alterations in blood glucose levels. Both hypoglycemia and hyperglycemia have been reported, so it is important to check glucose levels to ensure they remain within a normal range.