A client with congestive heart failure presents with swollen ankles, legs, and abdomen. The nurse should document these findings as:
Clubbing
Peripheral edema
Pitting edema
Ascites
The Correct Answer is B
A) This choice is incorrect because clubbing refers to the enlargement of the fingertips and nails due to chronic hypoxia, which is not related to the client's reported symptoms.
B) This choice is correct. Peripheral edema refers to swelling in the legs, ankles, and feet, which is a common symptom of congestive heart failure. The client's symptoms of swollen ankles, legs, and abdomen indicate peripheral edema.
C) This choice is incorrect because pitting edema is a specific type of edema where pressure on the skin leaves an indentation or "pit." While the client's edema may indeed be pitting, the question does not provide enough information to confirm this.
D) This choice is incorrect because ascites is the accumulation of fluid in the abdominal cavity and is not specific to the client's reported symptoms of swollen ankles and legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because restricting all physical activity is not recommended for clients with congestive heart failure. Regular, moderate exercise can be beneficial for heart health when appropriately prescribed by the healthcare provider.
B) This choice is correct. Regularly weighing themselves, ideally daily, and reporting sudden weight gain to the healthcare provider is essential for clients with congestive heart failure. Sudden weight gain may indicate fluid retention, a worsening of heart failure, or medication non-compliance.
C) This choice is incorrect because a high-sodium diet can worsen fluid retention and exacerbate congestive heart failure symptoms. The client should follow a low-sodium diet to manage fluid balance.
D) This choice is incorrect because taking prescribed medications only when symptoms worsen is not appropriate for congestive heart failure management. The client should take prescribed medications as directed by the healthcare provider, even when feeling well, to prevent symptom exacerbation and improve heart function.
Correct Answer is C
Explanation
A) This choice is incorrect because a complete blood count (CBC) is a general blood test that measures different components of the blood, such as red blood cells, white blood cells, and platelets. It is not specifically used to measure heart strain or diagnose CHF.
B) This choice is incorrect because a basic metabolic panel (BMP) is a blood test that measures electrolytes, kidney function, and glucose levels. It is not specific to diagnosing CHF.
C) This choice is correct. A brain natriuretic peptide (BNP) level is a blood test specifically used to measure heart strain. Elevated BNP levels can indicate heart failure, making it a valuable diagnostic tool in assessing suspected CHF.
D) This choice is incorrect because a C-reactive protein (CRP) level is a marker of inflammation and is not specific to diagnosing CHF.
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