The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Ascending edema

The client has no desire to eat.

The client sleeps on three pillows at night.

The client has a five pound weight gain.

Answer and Explanation

The Correct Answer is C

A. Ascending edema:

Ascending edema, also known as dependent edema, is typically associated with right-sided heart failure rather than left-sided heart failure. In right-sided heart failure, the heart's ability to pump blood to the lungs for oxygenation is compromised, leading to fluid backup in the systemic circulation. This fluid accumulates in the dependent areas of the body, such as the lower extremities (legs and ankles), causing swelling that can ascend upwards if left untreated. However, ascending edema is not a characteristic finding in left-sided heart failure, where pulmonary congestion and orthopnea are more common manifestations.

B. The client has no desire to eat:

While decreased appetite can occur in heart failure due to various factors such as fluid retention, abdominal bloating, or medication side effects, it is not a specific hallmark of left-sided heart failure. Symptoms such as fatigue, dyspnea (shortness of breath), orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (PND) are more commonly associated with left-sided heart failure. These symptoms result from the impaired function of the left ventricle, leading to pulmonary congestion and inadequate oxygenation.

C. The client sleeps on three pillows at night:

This choice is the correct answer. Sleeping on three pillows at night is a classic manifestation of orthopnea, a condition commonly seen in left-sided heart failure. Orthopnea refers to difficulty breathing while lying flat, which is alleviated by elevating the head and upper body with multiple pillows or sleeping in a semi-upright position. Orthopnea occurs due to the redistribution of fluid from the legs and lower body to the lungs when lying down, resulting in pulmonary congestion and respiratory distress.

D. The client has a five-pound weight gain:

Weight gain is a common symptom of fluid retention in heart failure; however, a specific weight gain of five pounds alone may not be indicative of left-sided heart failure without considering other clinical signs and symptoms. In heart failure, weight gain is often associated with fluid overload, which can lead to edema, dyspnea, orthopnea, and other signs of congestion. It's important to assess the client comprehensively for fluid status, including evaluating for edema, respiratory symptoms, and changes in weight over time, to determine the underlying cause of weight gain.

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Correct Answer is D

Explanation

A. Pleurisy:

Pleurisy is inflammation of the pleura, which is the lining surrounding the lungs. It can cause sharp chest pain that worsens with breathing. While pleurisy can be associated with conditions such as infections, pneumonia, or pulmonary embolism, it is not typically directly diagnosed or investigated using the brain (B-type) natriuretic peptide (BNP) test. The symptoms of pleurisy may include chest pain, especially with deep breathing, coughing, or sneezing.

B. Cardiomyopathy:

Cardiomyopathy refers to diseases of the heart muscle, which can lead to impaired heart function. Cardiomyopathy can cause symptoms such as fatigue, shortness of breath, chest pain, and fluid retention. While elevated BNP levels can be observed in some cases of cardiomyopathy, the BNP test is not specific to cardiomyopathy alone. It is often used to assess and diagnose heart failure, a condition that can result from various cardiac abnormalities, including cardiomyopathy.

C. Valve Dysfunction:

Valve dysfunction refers to abnormalities or malfunctions of the heart valves, such as stenosis (narrowing) or regurgitation (leakage). Valve dysfunction can lead to symptoms such as shortness of breath, chest pain, palpitations, and fatigue. While valve dysfunction can contribute to heart failure by causing pressure and volume overload on the heart chambers, the BNP test is primarily used to assess heart failure itself rather than specifically identifying valve dysfunction.

D. Heart Failure:

Heart failure is a condition in which the heart is unable to pump blood effectively to meet the body's needs. It can cause symptoms such as fatigue, shortness of breath, fluid retention (edema), and exercise intolerance. Elevated BNP levels are commonly observed in patients with heart failure, especially in cases of acute exacerbations or decompensated heart failure. The BNP test is used to assess and diagnose heart failure, as higher BNP levels indicate increased cardiac stress and volume overload.

A. Anxiety B. Sleep C. Fever D. Hyperglycemia E. Blood loss

Correct Answer is ["A","C","E"]

Explanation

A. Anxiety:

Anxiety can lead to an increased heart rate due to the activation of the sympathetic nervous system. When a person is anxious, their body releases stress hormones like adrenaline, which can stimulate the heart to beat faster. This increased sympathetic activity can cause sinus tachycardia, where the heart rate is faster than normal.

B. Sleep:

While sleep can affect heart rate variability, causing fluctuations in heart rate during different stages of sleep, it typically does not cause a significant and sustained increase in heart rate like sinus tachycardia. Sleep is more likely to influence heart rate patterns rather than directly cause sinus tachycardia.

C. Fever:

Fever, especially in response to infection or inflammation, can lead to an elevated heart rate. The body's response to fever includes increased metabolic activity, which can raise the heart rate as part of the physiological stress response. Fever-induced sinus tachycardia is a common finding in individuals with infections.

D. Hyperglycemia:

While hyperglycemia (high blood sugar levels) can have cardiovascular effects over time, such as contributing to atherosclerosis and heart disease, it is not typically a direct cause of sinus tachycardia. Sinus tachycardia is more commonly associated with acute stressors like anxiety, fever, or hypovolemia (such as from blood loss).

E. Blood loss:

Significant blood loss, such as during surgery or due to trauma, can result in hypovolemia, where there is a decrease in blood volume circulating in the body. In response to hypovolemia, compensatory mechanisms kick in, including an increase in heart rate (sinus tachycardia), to maintain blood pressure and perfusion to vital organs.

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The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis?

Correct Answer is D

Explanation

The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Correct Answer is ["A","C","E"]

Explanation

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