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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Cyanosis, or a bluish discoloration of the skin, occurs when there is insufficient oxygen in the blood, which can result from decreased perfusion due to clotting in DIC. It is a sign of poor oxygenation and perfusion.
B. While petechiae (small red or purple spots) are a common manifestation of DIC due to microvascular clotting and bleeding, they are not a sign of decreased perfusion.
C. Epistaxis (nosebleeds) is another bleeding manifestation of DIC but is not indicative of decreased perfusion, which is more closely related to cyanosis.
D. Hematuria (blood in the urine) can occur in DIC due to clotting in the kidneys or urinary tract. However, it is more related to bleeding than to decreased perfusion.

A. Heart rate 100 beats per minute B. + 3 peripheral edema C. Respiratory rate of 24 at rest D. Alert and oriented X 3

Correct Answer is D

Explanation

A. A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B. Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C. A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D. Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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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?