A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?
a. "Do you have trouble breathing or chest pain?"
b. "Are you able to walk upstairs without fatigue?"
c. "Do you awake with breathlessness during the night?"
d. "Do you have new-onset heaviness in your legs?"
ANS: B
Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.
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