A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?
"I have experienced blurred vision on several occasions."
"I must stop halfway up the stairs to catch my breath."
"I have been drinking more water than usual."
"I am awakened by the need to urinate at night."
The Correct Answer is B
A. Blurred vision is not a typical symptom of left-sided heart failure.
B. Difficulty breathing while performing activities, such as climbing stairs, is a classic symptom of left-sided heart failure due to pulmonary congestion.
C. Increased water intake is not directly indicative of left-sided heart failure.
D. Nocturia can occur in heart failure, but it is less specific than dyspnea on exertion.
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Related Questions
Correct Answer is D
Explanation
A. Bilateral peripheral edema can occur after heart catheterization but is not as immediately life-threatening as cardiac tamponade.
B. A heart rate of 59 beats/min may be concerning, but bradycardia alone is not as immediately urgent as signs of cardiac tamponade.
C. A temperature of 96°F is low, but this is more of a concern for hypothermia or post-procedural effects and is not as urgent as muffled heart sounds indicating tamponade.
D. Muffled heart sounds can indicate cardiac tamponade, a medical emergency. Immediate intervention is required to relieve the pressure on the heart, which may involve pericardiocentesis to drain the fluid or blood.
Correct Answer is B
Explanation
A. Administering oxygen is unnecessary at this time, as the client’s oxygen saturation is normal at 96%.
B. The client has had a myocardial infarction, which can lead to complications such as orthostatic hypotension or cardiovascular strain with sudden position changes. A bedside commode minimizes the need for the client to get out of bed and reduces the risk of these complications.
C. Suggesting the use of a bedpan may be an alternative but is less comfortable and may not adequately address the risk of strain from getting out of bed.
D. Allowing continued bathroom privileges may be unsafe, as it may increase the risk of a fall or cardiovascular strain.
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