A nurse is reviewing the history and physical of a client who has right ventricular heart failure.
Which of the following is an expected finding?
Crepitus
Elevated pulmonary artery pressure
Hepatosplenomegaly
Confusion
The Correct Answer is B
A. Crepitus is not typically associated with right ventricular heart failure; it may indicate subcutaneous emphysema or air leakage into the tissues.
B. Right ventricular heart failure often leads to elevated pulmonary artery pressure due to increased pressure in the pulmonary circulation.
C. Hepatosplenomegaly may occur in congestive heart failure but is not specific to right ventricular heart failure.
D. Confusion may occur in severe cases of heart failure due to decreased cerebral perfusion, but it is not specific to right ventricular heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.
B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.
C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.
D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.
Correct Answer is D
Explanation
A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.
B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.
C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.
D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.
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