A client admitted with heart failure is able to initiate brushing their teeth and combing their hair but unable to finish these activities or wash their body due to dyspnea and fatigue. Upon ambulation to the bathroom, the patient also experiences dyspnea, fatigue, and chest pain. Based upon this information, what New York Heart Association Classification will be assigned to this client?
I
II
IV
III
The Correct Answer is D
A. Class I: No limitation of physical activity; ordinary activity does not cause symptoms. This client clearly experiences symptoms with ordinary activities.
B. Class II: Slight limitation of physical activity; comfortable at rest, but ordinary activity causes fatigue, dyspnea, or chest pain. This client is more limited than Class II.
C. Class IV: Unable to carry out any physical activity without discomfort; symptoms may be present even at rest. This client does not have symptoms at rest.
D. Class III: Marked limitation of physical activity; comfortable at rest, but less-than-ordinary activity (e.g., brushing teeth, walking to the bathroom) causes fatigue, dyspnea, or chest pain. This best fits the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Airway: Ensure the airway is open.
B. Breathing: Provide rescue breaths if the person is not breathing.
C. Circulation: Begin chest compressions to maintain blood flow.
D. Defibrillation: Use an automated external defibrillator (AED) as soon as it's available, especially in cases of shockable rhythms like ventricular fibrillation.
Correct Answer is C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
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