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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the woman to call 911: This is a correct action, but it should be the second step after the nurse initiates first aid measures. Directing someone to call for emergency assistance is crucial, but immediate intervention to relieve the choking takes precedence.
B. The Heimlich maneuver involves abdominal thrusts and is the recommended technique for relieving choking in a conscious person. It is essential to act quickly and decisively to clear the airway.
C. Ask the partner if he can speak: If the person is unable to speak, cough, or breathe, it may indicate complete airway obstruction. The nurse should not delay intervention by asking if the person can speak but should immediately proceed with measures to relieve the choking.
D. Perform chest compressions: Chest compressions are not indicated for a conscious choking victim. Chest compressions are performed in the context of cardiopulmonary resuscitation (CPR) for an unconscious person with no pulse.
Correct Answer is A
Explanation
A. Excessive thrombosis and bleeding
Disseminated Intravascular Coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, leading to both excessive clot formation (thrombosis) and simultaneous consumption of clotting factors and platelets, resulting in bleeding. DIC can occur as a secondary complication to various conditions such as sepsis, trauma, or obstetric complications.
B. Increased clotting factors: In DIC, there is consumption and depletion of clotting factors, not an increase.
C. Progressive increase in platelet production: Platelet production does not increase in DIC; instead, there is consumption and decreased platelet count.
D. Immediate sodium and fluid retention: DIC is not associated with immediate sodium and fluid retention; instead, it is characterized by fluid loss due to bleeding.
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