The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?
Teach family members to assist with all ADLS once discharged
Cluster activities to a time when the client has the most energy
Provide alternating activity and rest periods
Limit self-care activities until symptoms subside
The Correct Answer is C
A. While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B. Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C. Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D. The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cryoprecipitate is indicated for low fibrinogen or clotting factor issues, but the client’s primary issue
here is anemia and thrombocytopenia.
B. FFP is used to replace clotting factors. While it could be considered in certain situations, in this case, the primary concern is the severe anemia and thrombocytopenia.
C. This is the most appropriate choice, as the patient has low hemoglobin (anemia) and a very low platelet count, both of which require packed red blood cells and platelets.
D. This combination is typically used for clotting factor issues, not anemia and thrombocytopenia.
Correct Answer is C
Explanation
A. Hypermagnesemia can cause bradycardia and hypotension, but it is less commonly associated with PVCs. This does not align with the lab results provided.
B. Hypocalcemia can cause arrhythmias, but it is not the most likely cause of PVCs in this case, considering other findings.
C. Hypokalemia (low potassium) is a known cause of PVCs. The patient's potassium level is 2.8 mEq/L, which is significantly low and most likely contributing to the PVCs.
D. Although hyperglycemia can affect cardiac function, it is less commonly linked to PVCs compared to electrolyte imbalances, such as hypokalemia.
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