The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)

Limit physical activity

Prevent endocarditis

Relieve the patient’s symptoms

Extend survival

Improve functional status

Answer and Explanation

Correct Answer : C,D,E

A. Limit physical activity

Limiting physical activity is not a primary goal in heart failure care. In fact, promoting appropriate and monitored physical activity is often part of the overall management plan. Exercise, when tailored to the client's condition, can improve functional status and quality of life.

B. Prevent endocarditis

While preventing endocarditis is important for individuals with certain cardiac conditions, it is not a primary goal in the care of heart failure. The focus is typically on optimizing cardiac function and managing heart failure symptoms.

C. Relieve the patient’s symptoms

Managing and relieving symptoms, such as dyspnea, fatigue, and fluid retention, are crucial goals in heart failure care. This includes optimizing medication management and other therapeutic interventions.

D. Extend survival

While heart failure is a chronic condition, the goal is to optimize treatment to improve the client's prognosis and overall survival. This involves the use of evidence-based therapies to address the underlying causes and contributing factors.

E. Improve functional status

Enhancing the client's ability to perform activities of daily living and improving functional capacity are important goals. This can involve a combination of medications, lifestyle modifications, and rehabilitation.

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Correct Answer is D

Explanation

A. Lie in a low Fowler’s or supine position:

Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.

B. Increase oral fluids unless contraindicated:

Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.

C. Increase activity:

Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.

D. Call the nurse for oral suctioning as needed:

This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.

A. “A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made.” B. “We will need to reevaluate your blood pressure because your age places you at high risk for hypertension.” C. “Hypertension is prevalent among men: it is fortunate we caught this during your routine examination.” D. “You have no need to worry. Your pressure is probably elevated because you are being tested.”

Correct Answer is A

Explanation

A. "A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made."

This response emphasizes the need for multiple elevated readings for a diagnosis of hypertension. It educates the individual about the diagnostic criteria and encourages them to seek further evaluation from their physician.

B. "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension."

This response might be seen as implying that age alone is a significant factor in determining hypertension, which may not be accurate. While age is a risk factor, the emphasis should be on the need for multiple readings and a physician's evaluation rather than attributing it solely to age.

C. "Hypertension is prevalent among men: it is fortunate we caught this during your routine examination."

This response suggests that the elevated blood pressure is automatically assumed to be hypertension based on gender. It is important to avoid making assumptions and instead focus on the need for proper evaluation and multiple readings for a hypertension diagnosis.

D. "You have no need to worry. Your pressure is probably elevated because you are being tested."

This response dismisses the individual's concerns and attributes the elevated blood pressure solely to the testing situation. While stress or anxiety can influence blood pressure readings, it's essential to address the need for further evaluation and not completely disregard the possibility of hypertension.

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The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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