A patient newly diagnosed with left-sided heart failure is admitted to the hospital. The nurse will observe this patient closely for:
Jugular vein distension.
Increased blood pressure.
Hepatomegaly.
Decreased urine output.
The Correct Answer is D
Choice A reason: This is not a sign of left-sided heart failure. Jugular vein distension is a sign of right-sided heart failure, which occurs when the right ventricle fails to pump blood effectively to the lungs.
Choice B reason: This is not a sign of left-sided heart failure. Increased blood pressure is a risk factor for developing heart failure, but it does not indicate the severity or location of the heart failure.
Choice C reason: This is not a sign of left-sided heart failure. Hepatomegaly is a sign of right-sided heart failure, which occurs when the right ventricle fails to pump blood effectively to the systemic circulation.
Choice D reason: This is a sign of left-sided heart failure. Decreased urine output is a result of reduced renal perfusion, which occurs when the left ventricle fails to pump blood effectively to the aorta and the rest of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a physiological response to hydralazine. Cool extremities are a sign of poor peripheral perfusion, which can be caused by vasoconstriction, not vasodilation.
Choice B reason: This is not a physiological response to hydralazine. Increased urinary output is a sign of diuresis, which can be caused by diuretic medications, not vasodilators.
Choice C reason: This is not a physiological response to hydralazine. Pale skin is a sign of reduced blood flow to the skin, which can be caused by vasoconstriction, not vasodilation.
Choice D reason: This is a physiological response to hydralazine. Reflex tachycardia is a compensatory mechanism that occurs when the blood pressure drops due to vasodilation. The heart rate increases to maintain the cardiac output and perfusion pressure.
Correct Answer is C
Explanation
Choice A reason: This is not the best response by the nurse. Stopping the medication abruptly can cause rebound hypertension and other complications. The patient should not stop taking the medication without consulting their health care provider.
Choice B reason: This is not the best response by the nurse. Cutting the pill in half and taking a reduced dosage can affect the efficacy and safety of the medication. The patient should not change the dosage of the medication without consulting their health care provider.
Choice C reason: This is the best response by the nurse. Dizziness is a common side effect of ACE inhibitors, especially when the patient changes position or stands up quickly. This is due to the orthostatic hypotension (a drop in blood pressure when standing up) caused by the vasodilation effect of the medication. However, this side effect is usually mild and transient, and can be prevented by rising slowly from a sitting or lying position, drinking plenty of fluids, and avoiding alcohol.
Choice D reason: This is not the best response by the nurse. Scheduling the patient to visit the health care provider today is not necessary, unless the dizziness is severe, persistent, or accompanied by other symptoms, such as chest pain, fainting, or palpitations. The patient should be advised to monitor their blood pressure and report any significant changes or concerns to their health care provider.
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