During an assessment, a client with congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care?
A) Excess Fluid Volume related to shortness of breath
B) Ineffective Family Management of Therapeutic Regime related to inability to purchase medications
C) Fatigue related to shortness of breath
D) Activity Intolerance related to shortness of breath
Answer: A
The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.
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