A client has a myocardial infarction in the left ventricle and develops crackles bilaterally: 3 pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
The development of chronic obstructive pulmonary disease (COPD)
The development of left sided heart failure
The development of right-sided heart failure
The development of cor pulmonale
The Correct Answer is B
A. The development of chronic obstructive pulmonary disease (COPD)
Explanation: The signs and symptoms described, including crackles, orthopnea, S3 heart sound, cough with pink, frothy sputum, and low pulse oximetry, are more indicative of heart failure than COPD.
B. The development of left-sided heart failure
Explanation: This is the correct answer. The signs and symptoms, such as crackles, orthopnea, and cough with pink, frothy sputum, are characteristic of left-sided heart failure. The S3 heart sound is often associated with increased ventricular filling pressures.
C. The development of right-sided heart failure
Explanation: The presented signs and symptoms are more consistent with left-sided heart failure. Right-sided heart failure is often associated with peripheral edema, hepatomegaly, and jugular venous distension.
D. The development of cor pulmonale
Explanation: Cor pulmonale is typically associated with right-sided heart failure due to chronic lung disease. The signs and symptoms described are more indicative of left-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Retinal Hemorrhage
Uncontrolled hypertension can damage the blood vessels in the eyes, leading to retinal hemorrhages. This can result in vision problems and, in severe cases, vision loss.
B. Ventricular Hypertrophy
Uncontrolled hypertension causes the heart to pump against increased resistance, leading to the thickening and enlargement of the left ventricle. Ventricular hypertrophy is a response to the increased workload on the heart and is associated with an increased risk of heart failure.
C. Cerebrovascular Disease
Hypertension is a major risk factor for cerebrovascular diseases, including strokes. Elevated blood pressure can damage the blood vessels in the brain, increasing the risk of stroke. Strokes can have serious consequences, affecting various neurological functions.
D. Venous Insufficiency
Venous insufficiency is not typically directly associated with uncontrolled hypertension. It is more commonly related to problems with the venous system, such as damaged valves in the veins, leading to poor blood flow back to the heart. While hypertension can affect arteries, venous insufficiency is a distinct condition.
E. Transient Ischemic Attacks (TIAs)
Uncontrolled hypertension increases the risk of transient ischemic attacks (TIAs), which are brief episodes of neurological dysfunction caused by temporary disruption of blood flow to the brain. TIAs are often considered warning signs of an increased risk of stroke.
Correct Answer is B
Explanation
A. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage
Explanation: This statement is not accurate. While a balanced diet is important, there is no specific recommendation to maintain a diet high in dairy to prevent organ damage related to hypertension.
B. Use of strategies to prevent falls stemming from postural hypotension
Explanation: This is a correct and important consideration. Beta-blockers can cause postural hypotension (a drop in blood pressure upon standing), and strategies to prevent falls, such as rising slowly from a sitting or lying position, are crucial.
C. Limiting exercise to avoid injury that can be caused by increased intracranial pressure
Explanation: This statement is not accurate. Exercise is generally beneficial for individuals with hypertension, and beta-blockers do not cause increased intracranial pressure.
D. Increasing fluids to avoid extracellular volume depletion from the diuretic effects of the beta-blocker
Explanation: This statement is not accurate. Beta-blockers are not typically associated with diuretic effects. Diuretics are a different class of medications commonly used for hypertension.
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