The nursing problem of activity Intolerance related to impaired ventricular function is made for a client with myocarditis. Which outcome in the plan of care would reflect resolution of this issue? The client will:

ambulate in the hall 3 times daily without shortness of breath.

have an increase in systolic blood pressure of 20 mmHg during activity.

decrease weight from 150 lbs. (68.2 kg.) to 148 lbs. (67.3 kg.) in five days.

verbalize the signs and symptoms of worsening heart failure by discharge.

Answer and Explanation

The Correct Answer is A

A. ambulate in the hall 3 times daily without shortness of breath: This directly reflects improved tolerance to activity, the central focus of the nursing diagnosis. Being able to ambulate without dyspnea indicates better cardiac output and ventricular function, marking resolution of the identified problem.

B. have an increase in systolic blood pressure of 20 mmHg during activity: A rise in systolic pressure may occur with exertion, but it does not necessarily indicate improved activity tolerance. In fact, an exaggerated BP response could indicate the heart is working harder than it should to meet the demands, suggesting poor cardiovascular adaptation to exercise.

C. decrease weight from 150 lbs. (68.2 kg.) to 148 lbs. (67.3 kg.) in five days: A slight weight reduction may reflect decreased fluid retention, but this outcome is more relevant to volume status and fluid balance than to resolving activity intolerance specifically.

D. verbalize the signs and symptoms of worsening heart failure by discharge:
While important for client education and self-management, this outcome relates to knowledge rather than physical tolerance to activity. It does not directly measure resolution of activity intolerance.

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Correct Answer is C

Explanation

A. Radiofrequency ablation: This is used to treat tachyarrhythmias such as atrial fibrillation, atrial flutter, or supraventricular tachycardia (SVT). The ECG shown does not demonstrate any tachycardic rhythm rather, it shows a bradyarrhythmia with dropped QRS complexes, which suggests a conduction block, not a reentrant circuit.

B. Administration of amiodarone: Amiodarone is primarily used for ventricular arrhythmias or atrial fibrillation. It is not effective in treating bradyarrhythmias or heart blocks such as those seen in this rhythm strip.

C. Insertion of a pacemaker: The rhythm strip shows intermittent dropped QRS complexes with consistent P waves—this is indicative of second-degree AV block, Mobitz II. This type of conduction block can progress to complete heart block and is often treated with the insertion of a permanent pacemaker to maintain cardiac output.

D. Administration of adenosine: Adenosine is used to terminate SVT by temporarily blocking AV node conduction. It is contraindicated in heart blocks, especially Mobitz II or third-degree AV block, because it can worsen the block and cause asystole.

A. Increase in systolic blood pressure 10 mmHg above client's norm B. reports dyspnea after walking up 2 flights of stairs C. Jugular vein distention and +3 peripheral edema D. Complaints of epigastric pain after eating a large meal

Correct Answer is C

Explanation

A. Increase in systolic blood pressure 10 mmHg above client's norm: A mild increase in systolic blood pressure is not a specific indicator of mitral stenosis progression. Blood pressure fluctuations may occur due to various factors and are not typically used as a primary marker of worsening valve disease.

B. reports dyspnea after walking up 2 flights of stairs: Exertional dyspnea is a common early symptom of mitral stenosis due to reduced left atrial emptying and pulmonary congestion. However, this does not necessarily indicate worsening unless the symptom becomes more severe or occurs with minimal exertion.

C. Jugular vein distention and +3 peripheral edema: These are signs of right-sided heart failure, which may result from long-standing mitral stenosis leading to pulmonary hypertension and subsequent right ventricular hypertrophy and failure. This indicates disease progression and worsening cardiac function.

D. Complaints of epigastric pain after eating a large meal: Epigastric discomfort is not a typical symptom of mitral stenosis and is more likely related to gastrointestinal issues. It does not reflect the status or progression of the cardiac condition.

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