The nurse is assessing a client who is diagnosed with heart failure and reports slight limitation of physical activity, is comfortable at rest but ordinary physical activity causes symptoms. What heart failure classification does this patient fall under?

Class II

Class IV

Class I

Class IlI

Answer and Explanation

The Correct Answer is A

A) Class II:
According to the New York Heart Association (NYHA) classification of heart failure, Class II is characterized by slight limitation in physical activity. Patients in this class are comfortable at rest but experience symptoms (such as fatigue, palpitations, or shortness of breath) during ordinary physical activity. This description fits the client's reported symptoms, which include comfort at rest and the onset of symptoms with routine activity, such as walking or climbing stairs.

B) Class IV:
Class IV is the most severe stage of heart failure. Patients in this class are unable to carry out any physical activity without discomfort and experience symptoms at rest, such as shortness of breath or fatigue. The symptoms do not improve with rest, and even minimal exertion exacerbates the condition.

C) Class I:
Class I heart failure is characterized by no limitation in physical activity. Patients in this class are able to carry out ordinary physical activity without fatigue, palpitations, or dyspnea. Since this client experiences symptoms with ordinary activity, they do not meet this criteria.

D) Class III:
Class III represents patients with marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or shortness of breath. While this client does report symptoms with ordinary physical activity, Class III patients experience greater limitation in activity than described in this scenario. The client in this case only has slight limitation with ordinary activity, so Class III does not apply.

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Correct Answer is D

Explanation

A. Hypertension:

Hypertension is not directly related to the rhythm displayed in the image. The rhythm is suggestive of atrial fibrillation (AF), characterized by irregular and chaotic electrical activity, leading to irregular heartbeats. Hypertension can be a risk factor for AF but is not a typical presenting symptom.

B. Indigestion:

Indigestion is a non-specific symptom that may occur in cardiac events like myocardial infarction but is not a hallmark of atrial fibrillation. The rhythm strip does not indicate myocardial ischemia.

C. Eupnea:

Eupnea refers to normal breathing, which is not commonly associated with atrial fibrillation. Clients with AF may experience symptoms such as shortness of breath or fatigue rather than normal, unlabored breathing.

D. Irregular palpitations:

This is the most expected finding. Atrial fibrillation leads to an irregularly irregular pulse, which patients often describe as palpitations. This rhythm strip demonstrates the hallmark chaotic atrial activity and irregular ventricular response seen in AF.

A. Use a razor to shave the hair in the treated area. B. Wash treated area gently with lukewarm water and mild soap. C. Purchase aloe approved skin-care products D. Wear loose-fitting, soft clothing over the treated skin. E. Sun tan the affected area for no more than 30 minutes a day

Correct Answer is ["B","C","D"]

Explanation

A) Use a razor to shave the hair in the treated area:
Shaving the treated area with a razor is not recommended during radiation therapy. The skin in the treated area becomes sensitive and fragile, so shaving could cause irritation, cuts, or abrasions. Instead, clients are usually advised to use electric razors or avoid shaving the area altogether. This instruction should not be followed to minimize the risk of injury.

B) Wash treated area gently with lukewarm water and mild soap:
This is a key self-care instruction for clients receiving radiation. Gentle cleansing with lukewarm water and mild soap helps to avoid further irritation to the skin, which can become dry and sensitive during radiation therapy. The treated area should not be scrubbed or rubbed, as this can cause damage to the skin, exacerbate dryness, or cause skin breakdown. This guideline is appropriate and should be followed.

C) Purchase aloe-approved skin-care products:
Using aloe vera or skin-care products approved for use during radiation therapy can help soothe and moisturize the skin, which often becomes dry, irritated, or sunburned from radiation. It is important to use products that are specifically designed for use during radiation to avoid any potential irritants or allergens. Aloe-based products or products recommended by the healthcare provider can provide relief and reduce side effects.

D) Wear loose-fitting, soft clothing over the treated skin:
Wearing loose-fitting, soft clothing is a crucial self-care recommendation for clients undergoing radiation. Tight or rough fabrics can irritate the sensitive skin, potentially leading to discomfort or skin breakdown. Soft fabrics like cotton are ideal, as they allow the skin to breathe and help avoid further friction or pressure on the treated area. This is an important aspect of skin protection during radiation therapy.

E) Sun tan the affected area for no more than 30 minutes a day:
Sun tanning or exposing the treated skin to direct sunlight is strictly forbidden during and after radiation therapy. The skin in the treated area is much more sensitive to UV radiation and can burn easily, even with minimal sun exposure. It can increase the risk of skin damage and delayed healing. The client should be advised to avoid direct sun exposure entirely and to wear protective clothing and sunscreen if they must be outdoors.

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The nurse is assessing a client who is diagnosed with heart failure and reports slight limitation of physical activity, is comfortable at rest but ordinary physical activity causes symptoms. What heart failure classification does this patient fall under?

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