A client who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as
Orthopnea
paroxysmal nocturnal dyspnea
pulsus alternans
acute bilateral pleural effusion
The Correct Answer is B
A. Orthopnea: Orthopnea is difficulty breathing when lying flat, but the client's description of waking up suddenly points to paroxysmal nocturnal dyspnea.
B. Paroxysmal nocturnal dyspnea: This is the correct answer. Paroxysmal nocturnal dyspnea occurs when a client with heart failure wakes up at night feeling suffocated due to fluid redistribution and pulmonary congestion.
C. Pulsus alternans: Pulsus alternans refers to alternating strong and weak heartbeats and is not related to the client's description of nocturnal dyspnea.
D. Acute bilateral pleural effusion: While pleural effusion can cause respiratory symptoms, paroxysmal nocturnal dyspnea is more specific to heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sinus rhythm is the normal rhythm of the heart with regular P waves, QRS complexes, and T waves. The presence of a sinus rhythm would mean the heart is pumping blood effectively, so the client would not be pulseless. This is inconsistent with the clinical scenario.
B. Ventricular tachycardia (VT) is a fast, regular rhythm originating in the ventricles. VT can lead to pulselessness if not treated, but it has distinct QRS complexes that are wide and regular, unlike the chaotic waveform seen in VF.
C. Ventricular Fibrillation appears as rapid, chaotic electrical activity without identifiable P waves, QRS complexes, or T waves. This rhythm prevents the heart from pumping blood, causing the client to be pulseless and unresponsive. VF is the most common arrhythmia associated with sudden cardiac arrest and requires immediate defibrillation.
D. Sinus tachycardia is a fast heart rate (>100 bpm) with regular rhythm, identifiable P waves, and QRS complexes. This rhythm typically occurs in response to stress, fever, or hypovolemia, and the client would have a pulse, which contradicts the scenario.
Correct Answer is A
Explanation
A. The best response is to educate the client about the cause of Prinzmetal angina. It occurs due to spasm in the coronary arteries, which is different from the plaque buildup seen in traditional coronary artery disease. This response addresses the client's concern in an accurate and reassuring manner.
B. While healthy eating is important, Prinzmetal angina is not typically caused by cholesterol or plaque buildup. This response could increase the client's anxiety.
C. While acknowledging the client's emotions is important, this response does not address the underlying concern or provide an accurate explanation of Prinzmetal angina.
D. Offering reassurance without providing accurate information about the condition does not help the client understand the cause of their symptoms and could leave them confused or anxious.
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