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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect. Anginal pain usually lasts less than 20 min and subsides with rest or medication. Pain that lasts longer than 20 min may indicate a myocardial infarction.

Choice B Reason: This is incorrect. Anginal pain usually responds to rest and organic nitrates, such as nitroglycerin. Pain that does not improve with these measures may indicate unstable angina or a myocardial infarction.

Choice C Reason: This is incorrect. Anginal pain is not aﬀected by the position of the client. Pain that is relieved by sitting up may indicate pericarditis or pleurisy.

Choice D Reason: This is correct. Anginal pain is caused by a temporary imbalance between the oxygen demand and supply of the myocardium. Factors that increase the oxygen demand, such as exertion, anxiety, cold, or heavy meals, can trigger anginal pain.

A. Attach the leads for a 12-lead ECG. B. Initiate oxygen therapy. C. Insert the IV catheter. D. Obtain a blood sample.

Correct Answer is B

Explanation

The correct answer is: B. Initiate oxygen therapy.

Choice A reason:

Attaching the leads for a 12-lead ECG is crucial for diagnosing a myocardial infarction. However, it is not the first priority. Ensuring the patient receives adequate oxygen is more critical to prevent further myocardial damage. The ECG can be performed immediately after oxygen therapy is initiated to confirm the diagnosis and guide further treatment.

Choice B reason:

Initiating oxygen therapy is the first priority because it ensures that the heart muscle receives adequate oxygen, which is essential to prevent further damage during a myocardial infarction. Oxygen therapy helps to maintain tissue oxygenation and can reduce the extent of myocardial injury. This immediate intervention is vital to stabilize the patient and improve outcomes.

Choice C reason:

Inserting the IV catheter is important for administering medications and fluids. However, it is not the first step. Oxygen therapy takes precedence to ensure the heart and other vital organs receive sufficient oxygen. Once oxygen is administered, IV access can be established to facilitate further treatment.

Choice D reason:

Obtaining a blood sample is necessary for confirming the diagnosis and assessing cardiac markers. However, it is not the immediate priority. Ensuring the patient is oxygenated is more urgent to prevent further myocardial damage. Blood samples can be drawn after oxygen therapy is initiated.

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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?

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