A 54-year-old man has a myocardial infarction, resulting in left-sided heart failure.
The nurse caring for the man is most concerned that he will develop edema in what area of the body.
Peripheral.
Pulmonary.
Liver.
Abdominal.
The Correct Answer is B
Choice A rationale
Peripheral edema is more commonly associated with right-sided heart failure rather than left-sided. This is because right-sided heart failure leads to systemic venous congestion, causing fluid to accumulate in the peripheral tissues, particularly in the legs and ankles.
Choice B rationale
Pulmonary edema is a major concern in left-sided heart failure due to the inability of the left ventricle to effectively pump blood out to the systemic circulation. This results in blood backing up into the pulmonary veins, leading to fluid accumulation in the lungs.
Choice C rationale
Liver edema, or hepatomegaly, is more typically seen in right-sided heart failure, where the failure of the right ventricle causes blood to back up into the systemic circulation, affecting the liver and other organs.
Choice D rationale
Abdominal edema, or ascites, is also more associated with right-sided heart failure. This condition occurs due to increased pressure in the veins and capillaries, leading to fluid leakage into the abdominal cavity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Analyzing data collected is part of the assessment phase, not the intervention phase.
Choice B rationale
Collecting a nursing history is part of the assessment phase of the nursing process, not the intervention phase.
Choice C rationale
Determining medication effectiveness is a critical aspect of the intervention phase, as it assesses the therapeutic outcomes of the administered drugs.
Choice D rationale
Documenting the medication is a key action in the intervention phase to ensure accurate and up-to-date patient records and safe administration.
Choice E rationale
Administering the medication is a direct intervention related to drug therapy and is part of the intervention phase.
Correct Answer is C
Explanation
Choice A rationale
Magnesium plays a role in muscle relaxation but is not primarily responsible for muscle contraction. It helps in stabilizing the muscle membrane by acting as a natural calcium blocker. Deficiency in magnesium can lead to muscle cramps and spasms, but it does not directly cause muscle contraction and relaxation processes.
Choice B rationale
Chloride is an essential electrolyte involved in maintaining fluid balance and acid-base balance, but it does not directly influence muscle contraction and relaxation. It works in conjunction with sodium to regulate osmotic pressure and acid-base balance.
Choice C rationale
Calcium is crucial for muscle contraction. It is released from the sarcoplasmic reticulum within the muscle cells and binds to troponin, causing a conformational change that allows actin and myosin to interact and generate contraction. During relaxation, calcium ions are pumped back into the sarcoplasmic reticulum.
Choice D rationale
Hydrogen ions are involved in pH balance and acid-base regulation but do not directly affect muscle contraction and relaxation. Excess hydrogen ions (acidosis) can impair muscle function, but they are not the primary factor in muscle contraction processes.
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