The nurse is assessing a client who is diagnosed with heart failure and reports slight limitation of physical activity, is comfortable at rest but ordinary physical activity causes symptoms. What heart failure classification does this patient fall under?

Class II

Class IV

Class I

Class IlI

Answer and Explanation

The Correct Answer is A

A) Class II:
According to the New York Heart Association (NYHA) classification of heart failure, Class II is characterized by slight limitation in physical activity. Patients in this class are comfortable at rest but experience symptoms (such as fatigue, palpitations, or shortness of breath) during ordinary physical activity. This description fits the client's reported symptoms, which include comfort at rest and the onset of symptoms with routine activity, such as walking or climbing stairs.

B) Class IV:
Class IV is the most severe stage of heart failure. Patients in this class are unable to carry out any physical activity without discomfort and experience symptoms at rest, such as shortness of breath or fatigue. The symptoms do not improve with rest, and even minimal exertion exacerbates the condition.

C) Class I:
Class I heart failure is characterized by no limitation in physical activity. Patients in this class are able to carry out ordinary physical activity without fatigue, palpitations, or dyspnea. Since this client experiences symptoms with ordinary activity, they do not meet this criteria.

D) Class III:
Class III represents patients with marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or shortness of breath. While this client does report symptoms with ordinary physical activity, Class III patients experience greater limitation in activity than described in this scenario. The client in this case only has slight limitation with ordinary activity, so Class III does not apply.

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Correct Answer is A

Explanation

A) Peaked T waves:
Peaked T waves are a classic sign of hyperkalemia on an EKG. As potassium levels rise, the T waves become taller, more pointed, and narrow, indicating changes in the heart's electrical conduction. This is one of the earliest and most characteristic EKG changes seen with hyperkalemia. Hyperkalemia can result from conditions such as kidney dysfunction, use of potassium-sparing diuretics, or other electrolyte imbalances.

B) Inverted P waves:
Inverted P waves typically suggest issues such as atrial ischemia or ectopic atrial rhythms but are not a hallmark sign of hyperkalemia. They may also appear with other conditions, like atrial fibrillation or atrial flutter. However, inverted P waves are not typically linked to elevated potassium levels.

C) Widened QRS:
A widened QRS complex can occur in several conditions, including hyperkalemia, but it is generally seen in more severe cases. As potassium levels rise further, the QRS complex may widen due to delayed conduction through the ventricles. Although a widened QRS can indicate hyperkalemia, it is a later sign, and it typically occurs after more specific changes like peaked T waves.

D) Prominent U wave:
Prominent U waves are more often associated with hypokalemia (low potassium levels) rather than hyperkalemia. U waves are typically seen after the T wave on the EKG and can be more prominent in conditions of low potassium.

A. Sodium 136 mEq/L B. Potassium 4.5 mEq/L C. Calcium 10 mg/dL D. Potassium 2.9 mEq/L

Correct Answer is D

Explanation

A) Sodium 136 mEq/L:
A sodium level of 136 mEq/L is within the normal reference range of 135–145 mEq/L. While clients with heart failure may experience fluid shifts and altered sodium levels, this result does not immediately require reporting to the provider. Sodium at this level is considered normal.

B) Potassium 4.5 mEq/L:
A potassium level of 4.5 mEq/L is within the normal range of 3.5–5.0 mEq/L, making it a safe and appropriate level. There is no immediate concern regarding potassium levels here, so no action is required. This value does not need to be reported to the provider.

C) Calcium 10 mg/dL:
The normal range for calcium is generally between 8.5–10.5 mg/dL. A calcium level of 10 mg/dL is within this normal range, so this finding does not require further action. No reporting is necessary to the provider.

D) Potassium 2.9 mEq/L:
A potassium level of 2.9 mEq/L is below the normal range (3.5–5.0 mEq/L) and is considered hypokalemia. Furosemide is a loop diuretic that can cause potassium depletion by increasing renal excretion of potassium. This is a serious concern because hypokalemia can lead to dangerous cardiac arrhythmias, muscle weakness, and other complications. The nurse should immediately report this low potassium level to the provider so that potassium supplementation or adjustments in diuretic therapy can be made.

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The nurse is assessing a client who is diagnosed with heart failure and reports slight limitation of physical activity, is comfortable at rest but ordinary physical activity causes symptoms. What heart failure classification does this patient fall under?

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