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 ["7.9"]
Explanation
Step 1: Identify the desired dose: 165 mg.
Step 2: Identify the concentration of the medication: 105 mg in 5 mL.
Step 3: Set up a proportion to find the required volume (x mL):
105 mg / 5 mL = 165 mg / x mL
Step 4: Solve for x:
105 × x = 165 × 5
Step 5:
105x = 825
Step 6:
x = 825 ÷ 105
Step 7:
x ≈ 7.857 mL
Final Answer: The nurse should give approximately 7.9 mL.
Correct Answer is D
Explanation
Choice A rationale
Anticipatory Grieving is a normal response to an expected loss, such as the impending death of oneself or a loved one. While the client is facing death, her statement "Why me, Lord" and inability to pray suggest a struggle with her spiritual beliefs and meaning in the face of this event, rather than primarily focusing on the emotional preparation for loss.
Choice B rationale
Ineffective Coping refers to an inability to manage stressors effectively. While the client's distress indicates difficulty coping with her situation, the specific mention of spiritual questioning and inability to pray points towards a disturbance in her spiritual well-being, which is more accurately described by spiritual distress.
Choice C rationale
Low Self-Esteem involves negative feelings about oneself and one's worth. While facing death can impact self-esteem, the client's direct questioning of her faith and inability to connect spiritually are the more prominent indicators in this scenario, suggesting a conflict or disruption in her spiritual domain rather than primarily a devaluation of self.
Choice D rationale
Spiritual Distress is characterized by a disruption in one's belief or value system that provides strength, hope, and meaning to life. The client's cry of "Why me, Lord" and her inability to pray indicate a struggle with her faith and a potential feeling of abandonment or questioning of her spiritual beliefs in the face of death. This aligns directly with the defining characteristics of spiritual distress.
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.