A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
Weight gain
Anorexia
Distended abdomen
Breathlessness
The Correct Answer is D
Choice A: Weight gain is not a manifestation of left-sided heart failure. Weight gain is more likely to occur in right-sided heart failure, as the blood backs up in the systemic circulation and causes fluid retention and edema in the body.
Choice B: Anorexia is not a manifestation of left-sided heart failure. Anorexia is a loss of appetite, which can have many causes, such as psychological disorders, infections, medications, or cancer. Left-sided heart failure does not directly affect appetite, but it can cause nausea, fatigue, and weakness.
Choice C: A distended abdomen is not a manifestation of left-sided heart failure. A distended abdomen is more likely to occur in right-sided heart failure, as the blood backs up in the portal vein and causes increased pressure in the liver and spleen. This can lead to hepatomegaly, splenomegaly, ascites, and varices.
Choice D: Breathlessness is a manifestation of left-sided heart failure. Breathlessness, or dyspnea, is a sensation of difficulty breathing or shortness of breath. Breathlessness occurs in left-sided heart failure, as the blood backs up in the lungs and causes pulmonary congestion and edema. This impairs gas exchange and reduces oxygen delivery to the tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a) is incorrect because troponin is not an enzyme, but a protein. Enzymes are molecules that speed up chemical reactions in the body. Troponin does not have this function.
Choice b) is correct because troponin is a protein that binds to calcium and regulates the contraction of heart muscle fibers. When the heart muscle is injured, such as in a myocardial infarction, troponin leaks into the bloodstream and can be detected by a blood test. The higher the level of troponin, the more severe the damage to the heart.
Choice c) is incorrect because troponin does not help transport oxygen throughout the body. That function is performed by hemoglobin, which is a protein found in red blood cells.
Choice d) is incorrect because troponin is not a lipid, but a protein. Lipids are fats that are used for energy storage and cell membrane formation. Troponin does not have these roles.
Correct Answer is C
Explanation
Choice A: Hct 45% is not a value that the nurse should report to the provider. Hct, or hematocrit, is the percentage of red blood cells in the total blood volume. The normal range for Hct is 37% to 51% for men and 32% to 45% for women. Hct 45% is within the normal range and does not indicate any abnormality.
Choice B: Platelets 160,000/mm³ is not a value that the nurse should report to the provider. Platelets, or thrombocytes, are cell fragments that help with blood clotting and hemostasis. The normal range for platelets is 150,000 to 450,000/mm³. Platelets 160,000/mm³ is within the normal range and does not indicate any abnormality.
Choice C: WBC 1,700/mm³ is a value that the nurse should report to the provider. WBC, or white blood cells, are cells that fight infection and inflammation. The normal range for WBC is 4,500 to 11,000/mm³. WBC 1,700/mm³ is below the normal range and indicates leukopenia, which is a low number of white blood cells. Leukopenia can be caused by various conditions, such as viral infections, autoimmune disorders, bone marrow suppression, or chemotherapy. Leukopenia can increase the risk of infection and sepsis and requires prompt evaluation and treatment.
Choice D: Hgb 14.7 g/dL is not a value that the nurse should report to the provider. Hgb, or hemoglobin, is a protein in red blood cells that carries oxygen to the tissues. The normal range for Hgb is 13.5 to 17.5 g/dL for men and 12.0 to 15.5 g/dL for women. Hgb 14.7 g/dL is within the normal range and does not indicate any abnormality.
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