Which clinical manifestation would the nurse use to indicate that the status of an older adult patient (greater than age 75) with chronic heart failure condition is worsening?

Presence of fine tremors

Heart rate 50 per minute

+1 peripheral edema

Increased confusion

Answer and Explanation

The Correct Answer is D

A. Presence of fine tremors: Fine tremors are not a typical sign of worsening heart failure. They may be associated with medications (like bronchodilators or lithium), metabolic issues, or neurologic disorders, but not directly with heart failure decompensation.

B. Heart rate 50 per minute: Bradycardia may be notable, especially in the context of beta-blocker therapy, but a heart rate of 50 bpm in a stable patient is not necessarily a sign of worsening heart failure unless accompanied by symptoms like dizziness or hypotension.

C. +1 peripheral edema: Mild peripheral edema is often chronic and common in older adults with heart failure. It does not reliably indicate worsening status unless there is a significant increase in edema or associated weight gain and pulmonary symptoms.

D. Increased confusion: Older adults are more susceptible to changes in cognitive function due to decreased cardiac output in worsening heart failure. New or worsening confusion in older adults is a key sign of decreased cerebral perfusion and may signal worsening heart failure. It can also indicate hypoxia or electrolyte imbalance, making it a critical finding that warrants immediate evaluation.

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Correct Answer is A

Explanation

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.

A. Blood pressure reading of 120/80 B. Urine output 30 mL for one hour C. Serum sodium level is 135 mEq/L (135-145) D. Respiratory rate 16 per minute

Correct Answer is D

Explanation

A. Blood pressure reading of 120/80: While a normal blood pressure is desirable, this value alone does not indicate improvement in fluid overload or pulmonary symptoms. It may remain normal even if respiratory status worsens or fails to improve.

B. Urine output 30 mL for one hour: Although urine output is an important measure of diuretic effectiveness, 30 mL/hr is the minimum acceptable rate, not necessarily a strong indicator of clinical improvement. More robust diuresis may be expected following IV furosemide.

C. Serum sodium level is 135 mEq/L (135–145): A normal sodium level reflects stable electrolyte status but does not directly indicate improvement in pulmonary congestion or dyspnea. Sodium may be affected by many factors unrelated to heart failure symptom relief.

D. Respiratory rate 16 per minute: A decrease in respiratory rate from 26 to 16 suggests improved oxygenation, reduced pulmonary congestion, and decreased work of breathing. It is the most direct and clinically relevant indicator of symptomatic improvement in this context.

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Which clinical manifestation would the nurse use to indicate that the status of an older adult patient (greater than age 75) with chronic heart failure condition is worsening?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

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