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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Wear a dosimeter badge and lead apron when providing direct patient care: When caring for a patient undergoing internal radiation therapy (brachytherapy), radiation safety is the nurse’s priority. The nurse must take measures to minimize radiation exposure by wearing protective equipment such as a dosimeter badge (to monitor exposure levels) and a lead apron (to shield against radiation). These precautions are critical to protect healthcare workers from potential radiation harm while caring for a patient with a radiation implant.
B) Avoid placing a radiation sign at the entrance of the room for patient privacy: Placing a radiation warning sign at the entrance of the room is a mandatory safety protocol when a patient is undergoing brachytherapy. This warning sign informs healthcare personnel and visitors that radiation is present, and it is important for ensuring safety. Patient privacy should not override radiation safety protocols.
C) Alert family members that they should restrict their visiting to 60 minutes at a time: While it is essential to inform family members about safety precautions when visiting a patient receiving radiation therapy, the priority action for the nurse is to ensure their own safety and radiation exposure first. Limiting family visits is an important step to reduce unnecessary exposure, but this is a secondary concern compared to the nurse's direct radiation safety measures.
D) Explain to the patient that she will continue to emit radiation for months after the implant is removed: The patient will continue emitting radiation only for a short period after the implant is removed. The duration of radiation emission depends on the type of radioactive material used in brachytherapy, but it is typically limited to a few days or weeks at most. In most cases, the nurse would explain to the patient that, after the implant is removed, radiation emission will cease.
Correct Answer is B
Explanation
A) Prednisone:
Prednisone is a corticosteroid commonly used to reduce inflammation in conditions such as asthma. It is appropriate in this case for managing the asthma exacerbation, as steroids help to decrease airway inflammation and improve breathing. There is no immediate concern about prednisone in this client with both asthma and a history of heart failure.
B) Metoprolol:
Metoprolol is a beta-blocker, typically used for managing heart failure, hypertension, and arrhythmias. However, beta-blockers are generally avoided in asthma patients because they can exacerbate bronchospasm. In patients with asthma, beta-blockers can block beta-2 receptors in the lungs, leading to constriction of the airways and worsening respiratory symptoms.
C) Labetolol:
Labetolol is a beta-blocker with both alpha- and beta-blocking effects, which can help lower blood pressure and manage heart failure. While labetalol can also block beta-2 receptors, it has a relatively lower risk of causing bronchospasm compared to non-selective beta-blockers like metoprolol. However, it still poses some risk to patients with asthma. Given the patient's history of asthma, labetolol may still require caution, but it is generally considered safer than other beta-blockers.
D) Albuterol:
Albuterol is a bronchodilator used to relieve acute asthma symptoms and is commonly prescribed for asthma exacerbations. It works by stimulating beta-2 receptors in the lungs, leading to the relaxation of bronchial smooth muscles and improved airflow. In this case, albuterol is an appropriate medication for managing asthma exacerbation and should be used to relieve symptoms of shortness of breath and wheezing.
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