The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)

Limit physical activity

Prevent endocarditis

Relieve the patient’s symptoms

Extend survival

Improve functional status

Answer and Explanation

Correct Answer : C,D,E

A. Limit physical activity

Limiting physical activity is not a primary goal in heart failure care. In fact, promoting appropriate and monitored physical activity is often part of the overall management plan. Exercise, when tailored to the client's condition, can improve functional status and quality of life.

B. Prevent endocarditis

While preventing endocarditis is important for individuals with certain cardiac conditions, it is not a primary goal in the care of heart failure. The focus is typically on optimizing cardiac function and managing heart failure symptoms.

C. Relieve the patient’s symptoms

Managing and relieving symptoms, such as dyspnea, fatigue, and fluid retention, are crucial goals in heart failure care. This includes optimizing medication management and other therapeutic interventions.

D. Extend survival

While heart failure is a chronic condition, the goal is to optimize treatment to improve the client's prognosis and overall survival. This involves the use of evidence-based therapies to address the underlying causes and contributing factors.

E. Improve functional status

Enhancing the client's ability to perform activities of daily living and improving functional capacity are important goals. This can involve a combination of medications, lifestyle modifications, and rehabilitation.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Retinal Hemorrhage

Uncontrolled hypertension can damage the blood vessels in the eyes, leading to retinal hemorrhages. This can result in vision problems and, in severe cases, vision loss.

B. Ventricular Hypertrophy

Uncontrolled hypertension causes the heart to pump against increased resistance, leading to the thickening and enlargement of the left ventricle. Ventricular hypertrophy is a response to the increased workload on the heart and is associated with an increased risk of heart failure.

C. Cerebrovascular Disease

Hypertension is a major risk factor for cerebrovascular diseases, including strokes. Elevated blood pressure can damage the blood vessels in the brain, increasing the risk of stroke. Strokes can have serious consequences, affecting various neurological functions.

D. Venous Insufficiency

Venous insufficiency is not typically directly associated with uncontrolled hypertension. It is more commonly related to problems with the venous system, such as damaged valves in the veins, leading to poor blood flow back to the heart. While hypertension can affect arteries, venous insufficiency is a distinct condition.

E. Transient Ischemic Attacks (TIAs)

Uncontrolled hypertension increases the risk of transient ischemic attacks (TIAs), which are brief episodes of neurological dysfunction caused by temporary disruption of blood flow to the brain. TIAs are often considered warning signs of an increased risk of stroke.

A. Diaphragmatic breathing B. Controlled breathing C. Pursed-lip breathing D. Use of accessory muscles

Correct Answer is D

Explanation

A. Diaphragmatic breathing:

Diaphragmatic breathing, also known as abdominal or deep breathing, is a normal and effective way of breathing. It involves the contraction and relaxation of the diaphragm, allowing for efficient lung expansion. This is a healthy and efficient breathing technique.

B. Controlled breathing:

Controlled breathing refers to a deliberate and regulated breathing pattern. It can include techniques such as paced breathing, where the individual consciously controls the rate and depth of their breaths. Controlled breathing is generally considered a positive and intentional approach to managing respiratory function.

C. Pursed-lip breathing:

Pursed-lip breathing is a breathing technique where the individual breathes in through the nose and exhales through pursed lips. This method is often taught to individuals with certain respiratory conditions, such as chronic obstructive pulmonary disease (COPD), to help improve lung function and alleviate shortness of breath. Pursed-lip breathing can be a helpful strategy in specific situations.

D. Use of accessory muscles:

The use of accessory muscles indicates that the person is experiencing increased difficulty in breathing. Accessory muscles, such as the neck and shoulder muscles, are not typically heavily involved in breathing under normal circumstances. When these muscles are visibly working during breathing, it suggests increased respiratory effort and can be a sign of respiratory distress or difficulty.

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The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe. (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

Correct Answer is D

Explanation

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