A goal of care for a client with congestive heart failure (CHF) is for serum sodium levels to be within normal limits. Which information documented in the medical record would indicate that the client is not meeting this goal?
A) The client is experiencing dependent edema.
B) The client experiences joint pain.
C) The client is constipated.
D) The client is experiencing wheezing respirations.
Answer: A
Communication is crucial in the medical field. The nurse who is taking over the client's care would note the goals of the current plan of care and would view the assessment to determine the reason for the nursing diagnosis and goals in order to be able to evaluate if goals have been met. Edema can be a result of a high sodium level. The nurse reviews the assessment to look for the reason the goal was set. Joint pain would be relevant for a different goal. Constipation would not be related to a high sodium level. Wheezing would be addressed by a different goal for the client.
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