The nurse is assessing a client who has a history of right-sided heart failure. Which assessment finding(s) is/are most consistent with this client’s diagnosis? (Select all that apply)
Pulmonary edema
Dependent edema
Abdominal swelling
Dry cough
Distended neck veins
Correct Answer : B,C,E
Choice A reason: Pulmonary edema is associated with left-sided heart failure, where blood backs up into the lungs, causing fluid leakage and crackles. Right-sided heart failure primarily affects systemic venous return, leading to peripheral and abdominal fluid accumulation, not pulmonary edema, making this inconsistent with the diagnosis.
Choice B reason: Dependent edema, such as ankle or leg swelling, occurs in right-sided heart failure due to impaired right ventricular pumping, causing blood to back up in systemic veins. This leads to fluid leakage into peripheral tissues, a hallmark symptom consistent with right-sided heart failure.
Choice C reason: Abdominal swelling, or ascites, results from right-sided heart failure due to increased venous pressure in the systemic circulation, causing fluid accumulation in the peritoneal cavity. This is a common and consistent finding, reflecting the systemic congestion caused by right heart dysfunction.
Choice D reason: Dry cough is typically associated with left-sided heart failure due to pulmonary edema irritating the airways. Right-sided heart failure causes systemic venous congestion, not pulmonary fluid buildup, so dry cough is not a primary or consistent symptom of this condition.
Choice E reason: Distended neck veins (jugular vein distension) occur in right-sided heart failure due to increased systemic venous pressure from impaired right ventricular emptying. This is a key clinical sign, reflecting the backup of blood in the venous system, consistent with right-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: ECT induces controlled seizures to treat severe depression, often causing short-term memory loss due to temporary disruption of hippocampal function. This is a common side effect, and clients should be informed to expect potential memory difficulties post-treatment.
Choice B reason: Atropine is used pre-ECT to reduce secretions, not post-procedure. Administering it afterward is unnecessary, as its role is to prevent airway complications during the procedure, making this an incorrect teaching point for ECT.
Choice C reason: Family attendance during ECT is not permitted due to the controlled medical environment, anesthesia, and seizure induction, which require privacy and safety protocols. This instruction is incorrect, as only medical personnel are present during the procedure.
Choice D reason: ECT is performed under general anesthesia, so the client is unconscious, not awake, during the procedure. Being awake would prevent safe seizure induction and monitoring, making this an incorrect and unsafe teaching point.
Correct Answer is D
Explanation
Choice A reason: Daily weight monitoring and reporting a 3-pound gain in one day indicates fluid retention, a sign of worsening heart failure. This is correct and shows understanding of self-monitoring to prevent complications, requiring no further teaching.
Choice B reason: Notifying the provider about increasing shortness of breath at rest is appropriate, as it signals worsening heart failure due to reduced cardiac output or pulmonary edema. This reflects proper understanding of symptom monitoring, requiring no additional teaching.
Choice C reason: A low-sodium diet reduces fluid retention in heart failure by decreasing sodium-induced water retention, preventing worsening of edema or congestion. This statement is correct and demonstrates understanding of dietary management, requiring no further teaching.
Choice D reason: Sleeping in a reclining chair may occur in severe heart failure due to orthopnea, but it is not a standard recommendation. It suggests poor symptom control, requiring further teaching on optimizing medical management, such as medication adherence and fluid monitoring, to prevent this need.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.