A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough

Abdominal distension

Dependent edema

Jugular venous distention

Answer and Explanation

The Correct Answer is A

A. Hacking cough: This is the correct answer. Left-sided heart failure can lead to pulmonary congestion, resulting in a cough that is often described as "hacking" or "persistent." This cough may be worse at night when the client is lying down.

B. Abdominal distension: Abdominal distension is more commonly associated with right-sided heart failure, as fluid accumulates in the abdomen (ascites). In left-sided heart failure, fluid accumulates in the lungs, leading to pulmonary symptoms.

C. Dependent edema: Dependent edema is also more commonly associated with right-sided heart failure. In left-sided heart failure, fluid tends to accumulate in the lungs, causing pulmonary congestion and related symptoms.

D. Jugular venous distention: Jugular venous distention is often seen in right-sided heart failure due to impaired blood flow from the right atrium into the right ventricle. This finding is less likely to be prominent in left-sided heart failure.

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Correct Answer is C

Explanation

A."I will follow a daily diet high in calories and protein": While maintaining adequate nutrition is important, emphasizing a diet high in calories may not be suitable. A balanced diet, including adequate protein, is recommended.

B."I will avoid getting a flu shot": Individuals with emphysema are at an increased risk of respiratory infections, including influenza. Getting a flu shot is generally recommended to reduce the risk of infection and complications.

C. "I will inhale slowly through pursed lips to help me breathe better."
This statement reflects a correct understanding of a beneficial breathing technique for individuals with emphysema. Inhaling slowly through pursed lips can help create back pressure in the airways, preventing them from collapsing and promoting better air exchange in the lungs. This technique can assist in managing shortness of breath and improving overall respiratory function.

D."I will lie on my stomach to practice abdominal breathing every day": While practicing abdominal breathing can be beneficial, lying on the stomach may not be the most practical or comfortable position for this purpose. The emphasis should be on proper breathing techniques, which can be done in various positions, including sitting or standing.

A. A friction rub B. A split second heart sound S₂ C. The third heart sound (S3) D. The fourth heart sound (S4)

Correct Answer is D

Explanation

A. A friction rub:A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.

B. A split second heart sound S₂:A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.

C. The third heart sound (S3):S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.

D. The fourth heart sound (S4):S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.

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A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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