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 D

Explanation

A. Dopamine and 50% non-rebreather mask: Dopamine is a vasopressor used in hypotension or shock, an inotropic agent used to improve cardiac output, not typically first-line for anxiety or respiratory distress. A non-rebreather mask may provide high oxygen levels but can be overwhelming and exacerbate anxiety if not well tolerated.

B. Nesiritide IV infusion and digoxin PO: Nesiritide is a vasodilator which may reduce preload and afterload in heart failure, and digoxin is a positive inotrope that can improve contractility, but neither offers rapid relief for anxiety and dyspnea. These medications have slower onset and are not used primarily for symptom control in acute distress.

C. Diazepam IV push and metoprolol IV: While diazepam may reduce anxiety, it can depress respiration, which is dangerous in decompensated heart failure with potential pulmonary edema. Metoprolol reduces heart rate and contractility and must be used cautiously in acute settings.

D. Morphine IV and oxygen 2 liters via nasal cannula: Morphine reduces preload, anxiety, and the sensation of breathlessness, making it ideal in acute decompensated heart failure. Low-flow oxygen improves oxygenation without overwhelming the patient. This combination directly targets both physiologic and psychological distress.

A. Sinus Bradycardia, with First Degree AV block. Rate 40 B. Second Degree AV block- Mobitz 1, Rate 40 C. Second Degree AV block-Mobitz II, Rate 40 D. Third Degree Heart Block. Rate 40

Correct Answer is A

Explanation

A. Sinus Bradycardia, with First Degree AV block, Rate 40: The rhythm strip shows regular P waves, each followed by a QRS complex, indicating a sinus rhythm. The PR interval is prolonged (greater than 0.20 seconds) but remains consistent across all beats. This confirms a first-degree AV block. The ventricular rate is approximately 40 bpm, consistent with sinus bradycardia.

B. Second Degree AV block – Mobitz I, Rate 40: Mobitz I (Wenckebach) is characterized by a progressively lengthening PR interval followed by a dropped QRS complex. This pattern is not seen here; the PR intervals are consistently prolonged.

C. Second Degree AV block – Mobitz II, Rate 40: Mobitz II involves intermittent dropped QRS complexes without progressive PR prolongation. In the strip, no QRS complexes are missing, ruling out Mobitz II.

D. Third Degree Heart Block, Rate 40: In complete heart block, there is no relationship between P waves and QRS complexes (AV dissociation). Here, the P waves are consistently followed by QRS complexes, indicating intact conduction, even if delayed. This therefore is not a third-degree block.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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