An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

Fatigue.

Lower extremity edema.

Hepatomegaly.

Jugular vein distension.

Answer and Explanation

The Correct Answer is A

Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the systemic circulation. This leads to fatigue and exertional dyspnea.
B. Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.
C. Hepatomegaly is a typical finding in right ventricular dysfunction
D. Jugular vein dysfunction is a typical finding in right ventricular dysfunction.

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Correct Answer is A

Explanation

A. This choice involves culturing a sputum sample collected from the patient to identify the presence of Mycobacterium tuberculosis, the bacterium that causes tuberculosis. A positive result confirms the diagnosis of TB.
B. Hemoccult tests are used to detect hidden (occult) blood in stool samples. While hemoptysis (coughing up blood) can be a symptom of TB, a hemoccult test is not specific for TB diagnosis. It is more commonly used in detecting gastrointestinal bleeding.
C. Imaging studies like chest x-ray or CT scans can reveal abnormalities in the lungs suggestive of TB, such as infiltrates, cavitations, or lymph node enlargement. While these tests can support the diagnosis, they are not definitive on their own.
D. The PPD skin test is a common screening tool for TB exposure. It detects the presence of a delayed hypersensitivity reaction to proteins derived from Mycobacterium tuberculosis. A positive PPD indicates exposure to TB but does not confirm active disease.

A. Administer a topical analgesic per protocol. B. Cleanse the tongue and mouth with swabs. C. Obtain a soft diet for the client. D. Encourage frequent mouth care.

Correct Answer is D

Explanation

D. Frequent mouth care helps maintain oral hygiene, reduces the risk of infection, and provides comfort to the client by removing debris and soothing irritated tissues.
A. Administering a topical analgesic may provide pain relief, but it should be done in accordance with the healthcare facility's protocol and after assessing the client's oral mucosa for any contraindications or precautions.
B. Cleaning the tongue and mouth with swabs can cause further irritation to the already sore oral tissues.
C. Obtaining a soft diet for the client is appropriate for minimizing trauma to the oral mucosa, but it may not address the immediate discomfort experienced by the client.

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An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

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An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?