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 B
Explanation
Choice A reason: Fewer numbers of parietal cells in the gastric mucosa is not the best explanation because it is a condition that affects the production of gastric acid, not the development of duodenal ulcers. Parietal cells are the cells that secrete hydrochloric acid and intrinsic factor in the stomach. Hydrochloric acid helps to digest food and kill bacteria, while intrinsic factor helps to absorb vitamin B12. Fewer numbers of parietal cells can cause hypochlorhydria, which is a low level of gastric acid, or pernicious anemia, which is a deficiency of vitamin B12. Hypochlorhydria can increase the risk of bacterial overgrowth and infections, while pernicious anemia can cause symptoms such as fatigue, weakness, and neurological problems.
Choice B reason: Helicobacter pylori infection is the best explanation because it is the most common cause of duodenal ulcers, which are sores that form in the lining of the first part of the small intestine, called the duodenum. Helicobacter pylori is a type of bacteria that can survive in the acidic environment of the stomach and the duodenum. It can damage the protective layer of mucus that covers the lining of the digestive tract, exposing it to the gastric acid and causing inflammation and ulceration. Helicobacter pylori infection can also increase the production of gastrin, which is a hormone that stimulates the secretion of gastric acid, and decrease the production of somatostatin, which is a hormone that inhibits the secretion of gastric acid.
Choice C reason: Slowed gastric emptying is not the best explanation because it is a condition that affects the movement of food from the stomach to the small intestine, not the development of duodenal ulcers. Gastric emptying is the process of passing the food that has been partially digested in the stomach to the duodenum, where it is further broken down and absorbed. Slowed gastric emptying can be caused by various factors, such as diabetes, medications, or nerve damage, and can result in symptoms such as nausea, vomiting, bloating, or fullness.
Choice D reason: Frequent use of acetaminophen is not the best explanation because it is a factor that affects the development of gastric ulcers, not duodenal ulcers. Acetaminophen is a type of medication that is used to relieve pain and fever. It can cause gastric ulcers by inhibiting the synthesis of prostaglandins, which are substances that protect the lining of the stomach from the gastric acid and promote healing. Acetaminophen can also cause liver damage if taken in high doses or for a long time.
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