The client has a diagnosis of systolic heart failure. Which statement does the nurse anticipate during the assessment?
"My feet swell up during the evening."
"It's harder to breathe during hot and humid weather."
"I wake up at night being short of breath."
"I have stomach pain that is worse after meals."
The Correct Answer is C
Choice A reason: "My feet swell up during the evening." is not a specific statement for systolic heart failure, but a general sign of fluid retention. Fluid retention may occur in both systolic and diastolic heart failure, as well as other conditions such as kidney disease, liver disease, or venous insufficiency.
Choice B reason: "It's harder to breathe during hot and humid weather." is not a specific statement for systolic heart failure, but a common complaint of many people with respiratory problems. Hot and humid weather may increase the workload of the lungs and the heart, but it does not indicate a reduced ejection fraction, which is the hallmark of systolic heart failure.
Choice C reason: "I wake up at night being short of breath." is the best statement for systolic heart failure, as it indicates a condition called paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is a sudden onset of breathlessness that occurs during sleep, usually due to fluid accumulation in the lungs. It is a sign of left-sided systolic heart failure, which is a failure of the left ventricle to pump blood effectively to the body.
Choice D reason: "I have stomach pain that is worse after meals." is not a specific statement for systolic heart failure, but a possible symptom of gastrointestinal disorders. Stomach pain may be caused by gastritis, ulcers, gallstones, or pancreatitis, among other conditions. It does not reflect the cardiac function or output, which are impaired in systolic heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Colon cancer is the most likely disorder that the client is at risk to develop because it is a type of cancer that affects the large intestine, which is the part of the digestive tract that absorbs water and forms stool. Colon cancer can be caused by various factors, such as genetics, diet, or inflammation. Ulcerative colitis is a chronic inflammatory bowel disease that causes ulcers and inflammation in the inner lining of the colon and rectum, which are the last parts of the large intestine. Ulcerative colitis can increase the risk of colon cancer by causing DNA damage and abnormal cell growth in the colon.
Choice B reason: Crohn disease is not the most likely disorder that the client is at risk to develop because it is a different type of inflammatory bowel disease that causes inflammation and damage in any part of the digestive tract, from the mouth to the anus. Crohn disease can be caused by various factors, such as genetics, immune system, or bacteria. Ulcerative colitis and Crohn disease have some similar symptoms, such as diarrhea, abdominal pain, or weight loss, but they are not the same condition and do not increase the risk of each other.
Choice C reason: Lactase deficiency is not the most likely disorder that the client is at risk to develop because it is a condition where the body does not produce enough lactase, which is an enzyme that breaks down lactose, which is a sugar that is found in milk and dairy products. Lactase deficiency can cause symptoms such as bloating, gas, or diarrhea after consuming lactose. Lactase deficiency can be caused by various factors, such as genetics, age, or intestinal injury. Ulcerative colitis does not affect the production of lactase, but it can cause lactose intolerance, which is a condition where the body cannot digest lactose properly due to the inflammation and damage of the colon.
Choice D reason: Irritable bowel syndrome is not the most likely disorder that the client is at risk to develop because it is a functional disorder that affects the movement and sensitivity of the bowel, causing symptoms such as abdominal pain, cramping, or constipation. Irritable bowel syndrome can be triggered by various factors, such as stress, food, or hormones. Irritable bowel syndrome does not cause inflammation or damage to the bowel, unlike ulcerative colitis, and it does not increase the risk of colon cancer.
Correct Answer is D
Explanation
Choice A reason: A sacculated aneurysm in the circle of Willis is not the most likely cause of a left-sided embolic stroke. A sacculated aneurysm is a bulging of a weak spot in the wall of an artery, which may occur in the circle of Willis, a network of arteries at the base of the brain. A sacculated aneurysm may cause a hemorrhagic stroke, which is a bleeding into the brain, not an embolic stroke, which is a blockage of a blood vessel by a clot.
Choice B reason: Rupture of small cerebral blood vessels is not the most likely cause of a left-sided embolic stroke. Rupture of small cerebral blood vessels may occur due to hypertension, diabetes, or aging, which may damage the integrity of the blood vessel walls. Rupture of small cerebral blood vessels may cause a hemorrhagic stroke, which is a bleeding into the brain, not an embolic stroke, which is a blockage of a blood vessel by a clot.
Choice C reason: Diffuse inflammation of the small diameter blood vessels is not the most likely cause of a left-sided embolic stroke. Diffuse inflammation of the small diameter blood vessels may occur due to vasculitis, which is an autoimmune disorder that causes inflammation and narrowing of the blood vessels. Diffuse inflammation of the small diameter blood vessels may cause a thrombotic stroke, which is a formation of a clot within the blood vessel, not an embolic stroke, which is a blockage of a blood vessel by a clot that travels from another site.
Choice D reason: Migration of a clot from the left atrium of the heart is the best explanation for the most likely cause of a left-sided embolic stroke. An embolic stroke is a type of ischemic stroke, which is a lack of blood flow to the brain due to a blockage of a blood vessel by a clot. A clot may form in the left atrium of the heart due to conditions such as atrial fibrillation, which is an irregular heartbeat that causes blood to pool and clot in the heart. A clot may then break off and travel through the bloodstream until it reaches a smaller blood vessel in the brain, where it causes an embolic stroke.
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