Which nursing diagnosis would the nurse add to the care plan of a patient diagnosed with acute systolic heart failure?
1. Disturbed Body Image
2. Imbalanced Nutrition: More than Body Requirements
3. Excess Fluid Volume
4. Ineffective Airway Clearance
3
Rationale 1: Disturbed Body Image is not a likely nursing diagnosis for this patient.
Rationale 2: If there is an imbalance in nutrition, it is more likely to be less than body requirements.
Rationale 3: Acute systolic heart failure is typically characterized by Excess Fluid Volume.
Rationale 4: Ineffective Airway Clearance is not applicable, as these patients do not have issues with clearing the airway as much as with impaired gas exchange.
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