Significant Nursing interventions required for a patient with activity intolerance include all, except?

SCTIMST Staff Nurse - 2015 (Set-B)

Fundamental of Nursing

Medium

Appeared in: SCTIMST Staff Nurse - 2015 (Set-B)

Explanation

A fluid-only diet is a nutritional measure, not a direct intervention for managing activity intolerance.
This diet is contraindicated as it leads to malnutrition, muscle catabolism (breakdown), and increased weakness, which would worsen the patient's condition.
Patients with activity intolerance require a balanced diet with adequate calories and protein to build energy reserves and muscle strength.
The primary management for activity intolerance involves balancing rest with gradually increasing activity and conserving energy.

Option A: This is a correct intervention. Range of Motion (ROM) exercises are crucial for maintaining joint flexibility and muscle tone, which helps prevent the deconditioning and contractures associated with prolonged inactivity.
Option B: This is a correct intervention. Using a wheelchair is a key energy-conservation strategy. It allows the patient to be mobile and participate in life activities without the high energy expenditure of walking, thus preventing excessive fatigue.
Option D: This is a correct intervention. Patient involvement is central to successful management. Allowing the patient to choose preferred activities increases motivation and adherence to a graded activity plan designed to progressively build endurance.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing management of activity intolerance to guide bedside assessment, documentation, and the next nursing action.
A primary nursing role is to teach patients with activity intolerance how to balance rest and activity, using energy conservation techniques to perform activities of daily living (ADLs) without excessive fatigue.
Nurses must continuously monitor the patient's physiological response to activity, including heart rate, blood pressure, respiratory rate, and oxygen saturation. Activity should be stopped if the patient shows signs of overexertion, such as chest pain, severe dyspnea, or dizziness.
What if? If the patient also has difficulty swallowing (dysphagia), a modified diet (like pureed or thickened liquids) would be necessary for safety. However, this is prescribed for swallowing issues, not for activity intolerance, and the goal would still be to provide maximum nutrition.

How to Approach the Question

First, recognize that the question includes the keyword 'except'. This means you must find the option that is an incorrect or inappropriate nursing intervention.
Next, understand the core concept: 'activity intolerance'. This is a condition where a patient lacks the energy for daily activities. Management focuses on conserving energy and gradually building endurance.
Evaluate each option based on these management principles.
Option A (ROM exercise) maintains muscle and joint function. This is appropriate.
Option B (wheelchair) is an energy-conservation technique. This is appropriate.
Option D (patient choice) promotes adherence to an endurance-building plan. This is appropriate.

Concept Tested & Keywords

Concept Tested: Nursing management of activity intolerance
Stem keywords: Nursing interventions, activity intolerance
Lead-in keywords: except
Negative lead-in flag: This is a negative-lead-in question asking you to identify the option that is NOT a correct nursing intervention.

QiRhqnDwgqS77vzzDJu5Lo

E6 Nursing Fundamentals Potter Perry 12e Part 4 p. 93-95

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 p. 15-17