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
Explanation
A. Mask:
Silicosis is a lung disease caused by inhaling crystalline silica dust. The primary preventive measure during exposure to silica particles is wearing a mask or respirator. This helps to reduce the inhalation of silica dust, protecting the respiratory system.
B. Gloves: Gloves are typically worn to protect the hands and skin and are not directly related to preventing inhalation of airborne particles.
C. Eye Protection: While eye protection is important in certain occupational settings, it does not specifically address the inhalation of silica particles.
D. Gown: Gowns are worn for protection against contamination but are not directly related to the prevention of occupational lung diseases such as silicosis.
Correct Answer is A
Explanation
A. "Did you have rheumatic fever as a child?"
Rheumatic fever is an inflammatory condition that can affect the heart, especially the heart valves. Rheumatic fever is a known risk factor for the development of valvular heart disease. Asking about a history of rheumatic fever helps identify a potential cause for valve malfunction.
B. "Do you have a family history of valve problems?"
Family history can be relevant in understanding genetic predispositions to certain cardiac conditions. While it may contribute to the overall assessment of cardiac risk, it may not be as directly linked to valve malfunction as a history of rheumatic fever.
C. "Do you have a history of MRSA?"
MRSA (Methicillin-resistant Staphylococcus aureus) is a type of bacterial infection and is not directly associated with valve malfunction. This question may be relevant for other aspects of the client's health but is not specific to ruling out cardiac issues related to valve malfunction.
D. "What over-the-counter medications do you take?"
While knowing the medications a client takes is important for a comprehensive assessment, asking about over-the-counter medications may not be as directly related to ruling out cardiac issues related to valve malfunction. It is more relevant for assessing potential interactions or effects on cardiovascular health.
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