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 C

Explanation

A. "I have a difficult time falling asleep at night":

Difficulty falling asleep at night is not typically a direct symptom of iron-deficiency anemia. While anemia can lead to fatigue and general tiredness, which might affect sleep quality, insomnia or difficulty falling asleep may have various causes unrelated to anemia. These causes can include stress, anxiety, poor sleep hygiene, or other underlying medical conditions.

B. "I have an increase in my appetite":

This choice is not directly related to iron-deficiency anemia. While some individuals with anemia may experience changes in appetite, such as increased hunger, this symptom is not specific to iron-deficiency anemia alone. An increase in appetite can have various causes, including hormonal changes, dietary changes, medications, or psychological factors.

C. "I have difficulty breathing when walking 30 feet":

This choice is the correct answer. Difficulty breathing, especially during exertion like walking, is a hallmark symptom of iron-deficiency anemia. Anemia reduces the oxygen-carrying capacity of the blood, leading to inadequate oxygen delivery to tissues, which can result in shortness of breath, fatigue, and difficulty with physical activities.

D. "I feel hot all of the time":

Feeling hot all the time is not a specific symptom of iron-deficiency anemia. While anemia can cause symptoms such as fatigue, weakness, pale skin, and shortness of breath, it does not directly lead to a constant feeling of heat or warmth throughout the body. Feeling hot or experiencing excessive sweating could be due to other factors such as hormonal changes, fever, hyperthyroidism, or environmental conditions.

A. Monitor weight daily B. Assess radial pulses daily C. Monitor bowel movements D. Monitor blood pressure daily

Correct Answer is A

Explanation

A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.

B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.

C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.

D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.

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

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