what nursing diagnosis would be most appropriate for a patient with heart failure

ATI RN

ATI Proctored Nutrition Exam

1. What nursing diagnosis would be most appropriate for a patient with heart failure?

A. risk for infection
B. fluid volume excess
C. impaired body temperature
D. ineffective airway clearance

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

2. An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:

A. Risk for injury directed to self
B. Risk for injury directed to others
C. Impaired nutrition less than body requirements
D. Ineffective individual coping

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. In preparation for ECT, the nurse knows that it is almost similar to that of:

A. ECG
B. General Anesthesia
C. EEG
D. MRI

Correct answer: B

Rationale: The correct answer is B: General Anesthesia. In preparation for ECT (Electroconvulsive Therapy), the nurse should be aware that it is almost similar to the process of administering general anesthesia. This similarity is crucial as it involves sedation and muscle relaxation to ensure safety during the procedure. Choice A (ECG) is incorrect because ECT and ECG (Electrocardiogram) serve different purposes and involve distinct procedures. Choice C (EEG) is incorrect as EEG (Electroencephalogram) measures brain activity and is not directly related to ECT. Choice D (MRI) is also incorrect as MRI (Magnetic Resonance Imaging) is a diagnostic imaging procedure that does not involve sedation or muscle relaxation like ECT and general anesthesia.

4. The community/Public Health Bag is:

A. a requirement for home visits
B. an essential and indispensable equipment of the community health nurse
C. contains basic medications and articles used by the community health nurse
D. a tool used by the Community health nurse is rendering effective nursing procedures during a home visit

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.