The nurse is reviewing assessment data for a client with a history of congestive heart failure who was admitted for shortness of breath. The client reported not having enough money to purchase medications

Question

Which of the following nursing diagnoses will be of the greatest initial importance when planning care? 1. Activity Intolerance related to shortness of breath
2. Fatigue related to shortness of breath
3. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications
4. Excess Fluid Volume related to shortness of breath

Answer 1

4. Excess Fluid Volume related to shortness of breath

Rationale:
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 management of therapeutic regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.