The nursing problem of activity Intolerance related to impaired ventricular function is made for a client with myocarditis. Which outcome in the plan of care would reflect resolution of this issue? The client will:

ambulate in the hall 3 times daily without shortness of breath.

have an increase in systolic blood pressure of 20 mmHg during activity.

decrease weight from 150 lbs. (68.2 kg.) to 148 lbs. (67.3 kg.) in five days.

verbalize the signs and symptoms of worsening heart failure by discharge.

Answer and Explanation

The Correct Answer is A

A. ambulate in the hall 3 times daily without shortness of breath: This directly reflects improved tolerance to activity, the central focus of the nursing diagnosis. Being able to ambulate without dyspnea indicates better cardiac output and ventricular function, marking resolution of the identified problem.

B. have an increase in systolic blood pressure of 20 mmHg during activity: A rise in systolic pressure may occur with exertion, but it does not necessarily indicate improved activity tolerance. In fact, an exaggerated BP response could indicate the heart is working harder than it should to meet the demands, suggesting poor cardiovascular adaptation to exercise.

C. decrease weight from 150 lbs. (68.2 kg.) to 148 lbs. (67.3 kg.) in five days: A slight weight reduction may reflect decreased fluid retention, but this outcome is more relevant to volume status and fluid balance than to resolving activity intolerance specifically.

D. verbalize the signs and symptoms of worsening heart failure by discharge:
While important for client education and self-management, this outcome relates to knowledge rather than physical tolerance to activity. It does not directly measure resolution of activity intolerance.

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Correct Answer is D

Explanation

A. Assist the client from the stretcher to a wheelchair: Immediately after electroconvulsive therapy (ECT), the client is still recovering from anesthesia and may experience confusion, drowsiness, or muscle weakness. Transferring the client prematurely poses a fall risk and is not appropriate as the first action.

B. Orient the client and offer reassurance: While reorientation and reassurance are important aspects of post-ECT care, safety and physiological stability must be assessed first. This action should follow an initial assessment of vital signs and level of consciousness.

C. Encourage the client to drink some fluids: Offering fluids too soon after ECT is inappropriate because the client may have impaired swallowing reflexes from anesthesia or sedation. Ensuring the airway is clear and the client is fully alert must precede oral intake.

D. Assess vital signs and orient client to the PACU environment: The priority after any procedure involving anesthesia is to assess vital signs to ensure hemodynamic stability and monitor for complications. Once stable, the nurse can begin to orient the client, which is often needed after ECT due to temporary disorientation or memory lapses.

A. gabapentin & acetaminophen B. extended release opioids C. sitting & leaning forward D. supine with head of bed 15 degrees

Correct Answer is C

Explanation

A. gabapentin & acetaminophen: While acetaminophen may help with pain relief, gabapentin is primarily used for neuropathic pain and not effective for the inflammatory chest pain associated with pericarditis. These medications do not address the positional nature of pericardial pain.

B. extended release opioids: Opioids may provide general pain relief but are not the standard treatment for pericarditis-related pain. They do not address the inflammatory cause and carry risks of sedation and respiratory depression without improving cardiac inflammation.

C. sitting & leaning forward: Pericarditis pain is classically relieved by having the patient sit up and lean forward. This position reduces pressure on the pericardium and decreases pain by allowing the inflamed pericardial layers to separate slightly, reducing friction.

D. supine with head of bed 15 degrees: Lying flat or even slightly elevated can worsen pericarditis pain because it increases pressure on the inflamed pericardium. Patients often report increased discomfort in the supine position, making it less favorable for symptom relief.

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The nursing problem of activity Intolerance related to impaired ventricular function is made for a client with myocarditis. Which outcome in the plan of care would reflect resolution of this issue? The client will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been admitted to the Post Anesthesia Care Unit (PACU) after a completing electroconvulsant therapy (ECT) treatment. Which action will the nurse perform first?

Correct Answer is D

Explanation

The nurse understands that chest pain related to pericarditis is classically relieved by

Correct Answer is C

Explanation

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