The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication?
Left-sided HF
Right-sided HF
Chronic heart failure (HF)
Acute decompensated heart failure (ADHF)
The Correct Answer is B
The assessment findings of jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute are consistent with right-sided heart failure (HF). Right-sided HF occurs when the right ventricle of the heart is unable to pump effectively, leading to congestion in the venous circulation. This can result in jugular venous distention (JVD) due to increased pressure in the jugular veins, peripheral edema due to fluid retention, and weight gain due to fluid accumulation.
Option A (Left-sided HF) may also present with similar symptoms like jugular venous distention, weight gain, and peripheral edema. However, in left-sided HF, there would typically be signs of pulmonary congestion, such as crackles in the lungs and shortness of breath.
Option C (Chronic heart failure) is a general term used for heart failure that has been present for an extended period, and it does not specify whether it is left-sided or right-sided heart failure.
Option D (Acute decompensated heart failure - ADHF) is a form of heart failure that presents with severe symptoms and requires urgent treatment. It is more of a clinical classification rather than a specific complication related to the symptoms mentioned in the scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Pericarditis is inflammation of the pericardium, the sac-like membrane surrounding the heart. It can cause chest pain, which is often worsened by deep breathing or coughing. The goal of treatment for pericarditis is to reduce inflammation and relieve pain.
In this case, the client's pain level is reported as 6 out of 10. As per the PRN (as-needed) medication options given:
C) Oral ibuprofen (Motrin) 600 mg: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and can help reduce inflammation and relieve pain in cases of pericarditis. It is an appropriate choice for this client's pain level of 6 out of 10.
A) IV morphine sulfate 4 mg: IV morphine is a potent opioid analgesic and may be appropriate for severe pain. However, in this case, the client's pain level is moderate (6 out of 10), and it is not the first-line medication for pericarditis pain.
B) Oral acetaminophen (Tylenol) 650 mg: Acetaminophen is a mild analgesic and antipyretic that can be effective for mild to moderate pain. However, in this situation, the client's pain is moderate (6 out of 10), and acetaminophen alone may not provide adequate relief for pericarditis pain.
D) Fentanyl 1 mg IV: Fentanyl is another potent opioid analgesic. However, similar to morphine, it may be more appropriate for severe pain, not moderate pain like in this scenario.
Based on the client's pain level and the goal of reducing inflammation, the most appropriate PRN medication for the nurse to give is oral ibuprofen (Motrin) 600 mg.
Correct Answer is D
Explanation
Discharge teaching for a client with heart failure and reduced ejection fraction should prioritize education about medications that are essential in managing heart failure, such as angiotensin-converting enzyme (ACE) inhibitors.
ACE inhibitors are a class of medications commonly prescribed to heart failure patients with reduced ejection fraction. They work by dilating blood vessels, reducing the workload on the heart, and improving the heart's pumping ability. They are one of the cornerstones of heart failure management and have been shown to reduce symptoms, improve quality of life, and prolong survival in heart failure patients.
Educating the client about the benefits and effects of ACE inhibitors is crucial to promote medication adherence and ensure they understand the importance of taking this medication as prescribed. Common side effects, such as dizziness or dry cough, should also be discussed so the client knows what to expect and when to notify their healthcare provider.
While the other options may also be relevant to a client with heart failure, including starting an aerobic exercise program (A), reducing salt intake (B), and scheduling regular follow-up appointments (C), the immediate priority in discharge teaching should be about the medication regimen and the specific benefits and effects of ACE inhibitors. Other aspects of heart failure management can be addressed during the overall education and follow-up sessions.
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