A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

Clubbing of the fingers

Bilateral crepitus

Bilateral peripheral edema

Increased anteroposterior diameter

Answer and Explanation

The Correct Answer is C

A. Clubbing of the fingers is a chronic finding associated with long-term hypoxia from respiratory diseases such as chronic lung disease or cystic fibrosis, not acute heart failure.
B. Bilateral crepitus suggests air trapping or alveolar collapse, which is more indicative of pneumonia or emphysema, rather than a primary cardiac cause.
C. Bilateral peripheral edema is correct. Dyspnea that worsens when lying flat (orthopnea) and the need for multiple pillows to sleep comfortably are signs of heart failure. Peripheral edema indicates fluid overload due to poor cardiac function.
D. Increased anteroposterior diameter is associated with chronic respiratory conditions like COPD, where lung hyperinflation leads to a "barrel chest" appearance. This is not a typical finding in heart failure.

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Correct Answer is C

Explanation

A. Vesicular breath sounds are soft, low-pitched sounds heard over most of the lung fields, characterized by a longer inspiratory phase and shorter expiratory phase.
B. Adventitious breath sounds refer to abnormal breath sounds such as crackles, wheezes, and rhonchi, but the described sound is a normal breath sound in the tracheal region.
C. Bronchial breath sounds are correct. These are high-pitched, harsh sounds with a short inspiratory phase and a long expiratory phase, normally heard over the trachea.
D. Bronchovesicular breath sounds are moderate in pitch and intensity, heard over the major bronchi rather than the trachea. They have equal inspiration and expiration durations rather than a longer expiratory phase.

A. Palpate for pitting edema. B. Assess for oral temperature. C. Inspect the oral mucosa. D. Auscultate adventitious lung sounds.

Correct Answer is C

Explanation

A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.

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A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

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Naxlex Comprehensive Predictor Exams

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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