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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
"If I could just live long enough to attend my son's graduation, I would be satisfied" represents bargaining, the third stage of grief according to Kübler-Ross. In this stage, the individual attempts to negotiate or make deals to postpone the inevitable.
Choice B rationale
"I believe there has been a mistake. I should have gotten a second opinion" is a classic example of denial, the first stage of grief. Denial is a defense mechanism where the individual refuses to accept the reality of the situation, often seeking alternative explanations or contradicting information.
Choice C rationale
"I know I am depressed and I can't stop crying" exemplifies depression, the fourth stage of grief. This stage is characterized by feelings of sadness, hopelessness, and withdrawal as the reality of the loss begins to sink in.
Choice D rationale
"I am very angry and mad. This is not fair" represents anger, the second stage of grief. In this stage, the individual expresses frustration, resentment, and outrage at the situation and may direct these feelings towards others. .
Correct Answer is B
Explanation
Choice A rationale
Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of all voluntary muscles except for those that control eye movement. The client's reported symptoms of drowsiness, irritability, and decreased attention span do not align with the typical presentation of locked-in syndrome, where cognitive function remains largely intact.
Choice B rationale
Sensory deprivation occurs when there is a reduction in sensory input, leading to various psychological and physiological effects. The client's recent loss of regular visits from her daughter and family, coupled with the reported symptoms of drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression, strongly suggest sensory deprivation as a contributing factor due to reduced social interaction and stimulation.
Choice C rationale
Residential psychosis is not a recognized or well-defined psychological or psychiatric term. Therefore, it is not an appropriate diagnosis for the client's symptoms.
Choice D rationale
Disturbed sensory perception involves alterations in the processing of sensory stimuli, such as hallucinations or delusions. While the client exhibits changes in her mental state, the reported symptoms are more indicative of a lack of sensory input and social interaction rather than distorted sensory processing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.