(1 point). Listen.
A patient has left-sided (congestive) heart failure.
Which assessment findings will indicate to the nurse that pulmonary edema has developed?
Syncope.
Weak pulses and decreased skin temperature.
Oliguria.
Dyspnea and cough.
The Correct Answer is D
Choice A rationale:
Choice A is not the answer. Syncope refers to fainting or losing consciousness, and it is not typically an assessment finding associated with pulmonary edema. The symptoms of pulmonary edema are more related to respiratory distress and fluid overload rather than loss of consciousness. Therefore, this statement is not relevant to the development of pulmonary edema in left-sided heart failure.
Choice B rationale:
Choice B is not the answer. Weak pulses and decreased skin temperature are not specific assessment findings for pulmonary edema. In pulmonary edema, patients often exhibit symptoms such as shortness of breath, wheezing, crackles in the lungs, and pink frothy sputum. These symptoms are related to the accumulation of fluid in the lungs, rather than changes in peripheral pulses or skin temperature.
Choice C rationale:
Choice C is not the answer. Oliguria refers to reduced urine output, and while it can be related to kidney dysfunction in some cases, it is not a direct assessment finding of pulmonary edema. Pulmonary edema primarily presents with respiratory symptoms, such as severe dyspnea, cough, and audible crackles in the lungs, due to fluid accumulation.
Choice D rationale:
The correct answer is choice D. Dyspnea and cough are key assessment findings that indicate to the nurse that pulmonary edema has developed in a patient with left-sided (congestive) heart failure. Pulmonary edema is characterized by the accumulation of fluid in the lungs, leading to severe difficulty in breathing (dyspnea) and a productive cough with frothy, pink-tinged sputum. These respiratory symptoms are typical of pulmonary edema and should alert the nurse to its presence. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"Permits blood to flow backward" is more characteristic of valvular regurgitation rather than stenosis. This choice is not accurate in the context of valvular stenosis.
Choice B rationale:
"Fails to shut completely" is a description of valvular regurgitation, not stenosis. This is not the correct choice.
Choice C rationale:
Stenosis of a heart valve means that the valve is constricted and narrowed, limiting the flow of blood through it. This choice is accurate and describes valvular stenosis correctly.
Choice D rationale:
"Regurgitates and causes insufficiency" is a description of valvular regurgitation, not stenosis. This choice is not appropriate in this context.
Correct Answer is C
Explanation
Choice A rationale:
Phosphorus. Rationale: Dysfunction in the normal secretion of natriuretic hormones is more likely to affect sodium and water balance, not phosphorus. Phosphorus levels are regulated by other mechanisms in the body and may not be directly influenced by natriuretic hormones. Choice A is incorrect.
Choice B rationale:
Calcium. Rationale: Calcium levels are not typically influenced by natriuretic hormones. Calcium regulation is primarily under the control of parathyroid hormone (PTH) and calcitonin. Dysfunction in natriuretic hormone secretion would not directly impact calcium levels. Choice B is incorrect.
Choice C rationale:
Sodium. Rationale: Natriuretic hormones, such as atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), play a crucial role in regulating sodium balance in the body. If a patient has dysfunction in the normal secretion of these hormones, it can lead to sodium imbalance, potentially causing sodium retention and fluid overload. Therefore, monitoring sodium levels is essential in such cases. Choice C is the correct answer.
Choice D rationale:
Aldosterone. Rationale: Aldosterone is a hormone that primarily regulates sodium and potassium balance in the body. Dysfunction in natriuretic hormone secretion is not directly related to aldosterone. Therefore, monitoring aldosterone levels would not be the most appropriate action in this context. Choice D is incorrect. .
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