A nurse is caring for a client with cardiomyopathy who is experiencing activity intolerance. Which intervention is inappropriate for this nursing diagnosis?

Correct Answer: C

Rationale: While the interventions of spacing out nursing activities, assisting with ADLs, and consulting with a physical therapist are appropriate for a client with cardiomyopathy experiencing activity intolerance, using passive and active range-of-motion exercises may not be suitable. In this condition, the heart muscle is weakened and may not be able to tolerate the increased activity associated with range-of-motion exercises. These exercises could potentially place additional strain on the heart and exacerbate symptoms such as shortness of breath and fatigue. It would be safer to focus on activities that do not overly stress the cardiovascular system while still promoting mobility and independence.

Correct Answer: D

Rationale: Virchow's triad describes the three pathological factors that are associated with the formation of a thrombus. These factors include endothelial injury, abnormal blood flow, and hypercoagulability. Endothelial injury disrupts the normal function of the endothelium, leading to the exposure of collagen and tissue factor, which triggers the coagulation cascade. Abnormal blood flow can result in stasis or turbulence, which promotes the accumulation of platelets and clotting factors. Hypercoagulability refers to an increase in the tendency of the blood to clot, which can be caused by various conditions such as genetic disorders, cancer, and certain medications. These three factors work together to increase the risk of thrombus formation.

Correct Answer: B

Rationale: In this situation, the nursing diagnosis of Ineffective Health Management is of the greatest initial importance when planning care. The client's inability to afford medications due to financial constraints directly affects their ability to manage their health effectively. Lack of funds may lead to non-adherence to the prescribed treatment plan, which can worsen the client's condition. By addressing the financial barriers to medication access, the nurse can help the client improve their health management and outcomes. This nursing diagnosis is a priority as it addresses the immediate need to ensure the client's access to necessary medications and prevent exacerbation of their congestive heart failure.

Correct Answer: C

Rationale: The correct strategy to prevent hypertension is to decrease stress. Chronic stress can lead to high blood pressure, so managing stress levels through techniques such as mindfulness, exercise, adequate sleep, and relaxation techniques can help prevent hypertension. It is not advisable to increase salt intake, reduce physical activity, or consistently take hot baths as these can exacerbate hypertension or have no significant impact on preventing it.

Correct Answer: B

Rationale: Monitoring the pulse and not taking procainamide hydrochloride if the pulse is less than a specified rate is a crucial aspect of medication adherence for clients receiving this medication. Procainamide hydrochloride is an antiarrhythmic medication that can affect conduction and increase the risk of dangerous dysrhythmias. Therefore, monitoring the pulse rate helps in early identification of potential adverse effects, such as heart block, that may necessitate withholding the medication and seeking medical attention. By adhering to this instruction, the client can actively participate in their care to ensure safe and effective treatment with procainamide hydrochloride.