An older woman tells the nurse that she has experienced increasing fatigue and shortness of breath over the last 2 days. Which goal is the nurse's priority?
a. Promote safety to prevent injury.
b. Complete nutritional assessment.
c. Balance exercise and rest periods.
d. Explore the woman's complaints.
D
Investigating the complaint is the nurse's priority; fatigue and shortness of breath can indicate cardiac disease, especially in women. Women with cardiac disease often exhibit atypical symp-toms, and because it tends to be treated less aggressively in women, the nurse must be careful not to miss indicators of potential cardiac disease. In addition, in investigating the older woman's chief complaint, the nurse investigates all possible causes.
Promoting safety and preventing injury are reasonable goals to include for this adult but are not as important as investigating the chief complaint; breathing and circulation are two of the three most important physical needs. Completing the nutritional assessment for this adult is rea-sonable because the symptoms can be related to nutritional deficiencies; however, this assessment should be a part of the examination of the chief complaint. Balancing rest and exercise is a reasonable approach to a complaint of fatigue and shortness of breath if the adult is decondi-tioned; however, the nurse must investigate the chief complaint to determine whether decondi-tioning is a factor.
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