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 D

Explanation

A. Reviewing sodium and bicarbonate levels is not the most immediate action. While these lab values may provide useful information, they do not directly assess the suspected condition.
B. Assessing for peptic ulcer disease is incorrect because a tight, distended abdomen with visible arterioles (caput medusae) is more indicative of liver disease, such as cirrhosis or portal hypertension, rather than a gastric ulcer.
C. Assessing the client’s nutritional status may be important, but it is not the priority in this situation. Malnutrition can be a consequence of liver disease, but the nurse should first focus on identifying the underlying condition.
D. Assessing the client for other signs and symptoms of liver disease is correct. A distended abdomen and visible arterioles suggest possible ascites and portal hypertension, both of which are common in liver disease. Further assessment for jaundice, hepatic encephalopathy, or changes in liver enzyme levels would be appropriate.

A. "Client's gastrointestinal health is within normal limits." B. "Gastrointestinal problems are not present at this time." C. "Client denies gastrointestinal signs and symptoms." D. "Client denies recent constipation, diarrhea, bowel incontinence or abdominal pain."

Correct Answer is D

Explanation

D. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain." is correct because it is the most specific and complete documentation of the client’s subjective report. It ensures clarity, accuracy, and thorough assessment.
A. This is incorrect because stating "within normal limits" is vague and does not specify what was assessed.
B. This is incorrect because stating "problems are not present" is too general and does not include specific symptoms the client was asked about.
C. This is incorrect because "denies gastrointestinal signs and symptoms" lacks specificity regarding which symptoms were assessed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Correct Answer is D

Explanation

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

Correct Answer is D

Explanation

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