The nurse is educating a client with heart failure on monitoring for signs and symptoms. Which ...

Correct Answer: 1
Rationale 1: Increased daily weight is a sign that a client could be decompensating. Daily weights are an effective means of monitoring for heart failure symptoms.
Rationale 2: Shortness of breath is not present in all stages of heart failure. Moreover, many clients self-treat shortness of breath by doing progressively less activity, and therefore never experience shortness of breath until late in the disease.
Rationale 3: Clients with heart failure often experience orthopnea, which is relieved by sitting up. Sleeping on three pillows can mask orthopnea.
Rationale 4: High heart rate and blood pressure are compensatory mechanisms and signs that the client still might be experiencing heart failure.
Global Rationale: Increased daily weight is a sign that a client could be decompensating. Daily weights are an effective means of monitoring for heart failure symptoms. Shortness of breath is not present in all stages of heart failure. Moreover, many clients self-treat shortness of breath by doing progressively less activity, and therefore never experience shortness of breath until late in the disease. Clients with heart failure often experience orthopnea, which is relieved by sitting up. Sleeping on three pillows can mask orthopnea. High heart rate and blood pressure are compensatory mechanisms and signs that the client still might be experiencing heart failure.