The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?
Teach family members to assist with all ADLS once discharged
Cluster activities to a time when the client has the most energy
Provide alternating activity and rest periods
Limit self-care activities until symptoms subside
The Correct Answer is C
A. While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B. Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C. Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D. The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D","dropdown-group-3":"D"}
Explanation
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Correct Answer is A
Explanation
A. Weigh daily on the same scale at the same time of day - Daily weight measurement is critical for clients with heart failure to monitor for fluid retention, which can indicate worsening heart failure.
B. Restrict foods that are high in potassium - This is not recommended unless the client is on certain medications (e.g., potassium-sparing diuretics) that cause high potassium levels. Generally, potassium- rich foods are beneficial for heart health.
C. Engage in aerobic activity for one hour each day - Although exercise is important, the intensity and duration should be individualized, and clients with heart failure may need to start with lower-intensity activity.
D. Monitor sugar intake - While important for diabetes management, monitoring sugar intake is not a primary focus for clients with heart failure unless they also have diabetes.
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