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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Free Nursing Study Resources

Correct Answer is B

Explanation

A) "ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication."
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that results in the progressive loss of motor neurons, which leads to muscle weakness, atrophy, and paralysis. It is not caused by "excess chemicals in the brain," and there are currently no medications that can cure ALS or completely control its symptoms. Medications such as riluzole can slow the progression slightly, but they do not stop or reverse the disease.

B) "The disease is progressive and will eventually lead to paralysis while maintaining cognitive function."
ALS is indeed a progressive neurodegenerative disease that leads to the gradual loss of muscle function due to the death of motor neurons. Over time, the patient will experience muscle weakness, atrophy, and paralysis, while the cognitive function typically remains intact until the later stages of the disease, although some patients may develop frontotemporal dementia. it is essential for the patient to understand that the disease will progressively impair their physical abilities while leaving cognitive functions largely unaffected in most cases.

C) "Before you lose cognitive function, you should consider creating an advanced directive."
While it is important for individuals with ALS to plan for the future, this statement is not entirely accurate. Cognitive function in ALS is often preserved throughout most of the disease, although there is a subset of patients who may develop frontotemporal dementia. It would be more appropriate to discuss advanced directives early in the disease, but it is not guaranteed that cognitive function will be lost before physical decline.

D) "Despite severe symptoms right now, most patients recover with treatment."
ALS is a progressive disease with no cure, and it does not typically result in recovery. While certain treatments can help manage symptoms or slow the progression of the disease, recovery is not a realistic expectation. Most patients with ALS experience gradual worsening of symptoms and ultimately may require assistance with daily activities as the disease progresses.

A. Stop taking, ordered corticosteroid once symptoms resolve. B. Apply warm compresses to the affected several times a day. C. Cover the affected eye with eye eye protective shield or patch at night. D. Chew food only on the affected side. E. Place artificial tears or lubricant to help decrease dryness in the eyes

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

Explanation

A) Stop taking ordered corticosteroid once symptoms resolve:
Corticosteroids, such as prednisone, are commonly prescribed to reduce inflammation in Bell’s Palsy, especially during the acute phase. However, it is important to complete the full course of corticosteroids as prescribed, even if symptoms improve. Abruptly stopping corticosteroids can lead to rebound inflammation and potentially worsen the condition.

B) Apply warm compresses to the affected area several times a day:
Warm compresses can help to reduce pain and inflammation in the affected side of the face. Applying them several times a day can also help improve circulation and ease the discomfort associated with Bell's Palsy. This is a recommended self-care strategy that can help provide relief and improve overall comfort for the client during recovery.

C) Cover the affected eye with an eye protective shield or patch at night:
Bell's Palsy can lead to paralysis of the facial muscles, which may make it difficult for the client to fully close the eyelid on the affected side, leaving the eye vulnerable to dryness and injury. Covering the eye with a protective shield or patch at night helps prevent corneal damage and protects the eye from exposure during sleep. This is an essential part of eye care for a client with Bell’s Palsy to prevent complications.

D) Chew food only on the affected side:
There is no medical recommendation to limit chewing to the unaffected side. In fact, clients should be encouraged to use both sides of their mouth for chewing to prevent muscle atrophy and maintain function. There is no evidence to support that chewing food only on the affected side provides any benefit.

E) Place artificial tears or lubricant to help decrease dryness in the eyes:
Since Bell's Palsy can impair the ability to close the eyelid fully, this can lead to dryness and potential corneal damage on the affected side. Artificial tears or lubricating eye drops should be used regularly to moisturize the eye and prevent complications such as corneal ulcers or abrasions.

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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?

Nursing Test Bank

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Correct Answer is B

Explanation

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