Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?
Fluid Volume Excess related to heart failure, as evidenced by edema and orthopnea.
Fluid Volume Deficit related to inadequate fluid intake, as evidenced by confusion and poor skin turgor.
Impaired Gas Exchange related to fluid accumulation in the lungs, as evidenced by orthopnea and shortness of breath.
Risk for Falls related to confusion and weakness.
The Correct Answer is A
Choice A rationale
Fluid Volume Excess occurs in congestive heart failure due to the heart's inability to pump blood effectively, leading to increased hydrostatic pressure in the capillaries. This pressure forces fluid into the interstitial spaces, causing edema. Orthopnea, or difficulty breathing while lying flat, results from the redistribution of this excess fluid into the pulmonary circulation when supine, increasing pressure in the lungs.
Choice B rationale
Fluid Volume Deficit is characterized by dehydration, typically presenting with symptoms like poor skin turgor, dry mucous membranes, and concentrated urine. Confusion in dehydration is due to reduced cerebral perfusion. These signs and symptoms are contrary to the findings of edema and orthopnea, which indicate fluid overload, not deficit.
Choice C rationale
Impaired Gas Exchange is a potential complication of congestive heart failure due to fluid accumulation in the lungs (pulmonary edema). While orthopnea is a symptom of this, the primary evidence for impaired gas exchange would be abnormal blood gas values (e.g., low PaO2, high PaCO2) and clinical signs of hypoxemia, not just orthopnea and shortness of breath alone.
Choice D rationale
Risk for Falls is a relevant concern for an elderly client with confusion, as altered mental status can impair judgment and coordination, increasing the likelihood of falls. However, this diagnosis does not directly address the primary physiological problem of fluid overload evidenced by edema and orthopnea in the context of heart failure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Impaired Skin Integrity involves damage to the epidermal and/or dermal layers of the skin. While excessive fluid loss can indirectly affect skin turgor and increase the risk of breakdown over time, the primary and immediate physiological consequence of increased urinary output due to a diuretic is a potential reduction in overall fluid volume within the body, not a direct impairment of skin integrity.
Choice B rationale
Impaired Urinary Elimination describes difficulties in controlling or completely emptying the bladder. A diuretic, by its mechanism of action, increases urine production and thus promotes urinary elimination. While the *pattern* of elimination may change (increased frequency, urgency), the fundamental issue is not an impairment of the elimination process itself but rather an *increase* in it.
Choice C rationale
Urinary Retention is the inability to empty the bladder completely. A diuretic works to increase urine output, directly counteracting the physiological process of urinary retention. Therefore, this nursing diagnosis would be inappropriate for a client experiencing increased urinary output due to diuretic use.
Choice D rationale
Risk for Deficient Fluid Volume is a nursing diagnosis that identifies a vulnerability to a decrease in intravascular, interstitial, and/or intracellular fluid, which may compromise health. A diuretic increases urinary output, leading to a greater loss of fluid from the body. Without adequate fluid intake to compensate for this increased loss, the client is at a significant risk of developing a fluid volume deficit.
Correct Answer is A
Explanation
Choice A rationale
The nurse practice act and agency policy provide the legal and organizational framework for nursing practice and delegation. Determining if the delegation of topical medication administration is permissible under these guidelines is the foundational first step to ensure legality and adherence to established protocols.
Choice B rationale
Assessing the UAP's training is crucial for safe delegation, but it's secondary to ensuring that the task is delegable in the first place according to legal and policy guidelines. Training is irrelevant if the task cannot be delegated.
Choice C rationale
Ensuring appropriate supervision is essential for delegated tasks, but again, it's contingent on whether the task can be legally and organizationally delegated. Supervision protocols come into play after the initial permissibility of delegation is established.
Choice D rationale
Evaluating the client's past response to the treatment is important for ongoing care but doesn't determine the initial delegability of the task to a UAP. The focus of the first question is on the legal and policy aspects of delegation. .
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